Triple fusion- For calcaneal fracture malunion

The on table appearance of a patient with a malunited, conservatively treated calacaneal fracture.
There is a subtle sense that the hindfoot is slightly broadened and set in valgus, from this non-weightbearing photograph.

The significant hindfoot valgus is well demonstrated in this on-table view of the hindfoot taken during surgical draping.

The lateral foot radiograph showing gross subtalar arthritis, a dorsiflexed talus and a fragmented anterior process calcaneum.
This technique is slightly unusual, in that there is such marked comminution and bone loss in the anterior process that talar inclination was correctable by allowing the talar head to plantar flex into the deficient anterior calcaneum. When the anterior process is intact, we would favour a bone block technique, whereby a tricortical bone block is placed into the posterior facet to restore height and correct the talar inclination. We felt in this case a bone block would reduce the surface area of direct contact between talus and calcaneum, which may have increased the risk of non-union.

A malunited calcaneal fracture demonstrating a grossly degenerate subtalar joint, and also loss of normal support for the talus.
This patient has painful subtalar arthritis (1), plantar pain from a large bony boss of malunited bone (2)as well as anterior ankle impingement(3).

The salvage procedure has been a distraction fusion of the subtalar joint. A large tricortical iliac crest graft (1) and morcellised autograft (partly from debridement of the lateral wall and plantar aspect of the calcaneus) are impacted into the prepared and corrected subtalar joint to re-support the talus posteriorly and allow it to return to its slightly plantar-flexed normal alignment (2).

AP radiograph left ankle demonstrating the lateral wall of calcaneum blown out(1) and sub-fibular impingement(2).

Inspection of the uninjured side makes the presence of the lateral wall impingement far more obvious

Axial CT scan shows fragmented, largely non united anterior process of calcaneum(1) with prominent lateral wall(2).

Coronal CT scan shows the blown out lateral wall of calcaneum(1) with the potential for subfibular impingement.

Sagittal CT scan shows plantar flexed posterior facet of the subtalar joint (1) and fragmented non union of the anterior process of calcaneum(2).
The combination of depressed posterior facet and fragmented non-united anterior process following non union provides a challenging reconstruction and arthrodesis, that is often overlooked in comparative studies of calcaneal fracture management.
Primary reduction and fixation of the calcaneum would have aimed at restoring height and alignment of the calcaneum; approaching a subtalar arthrodesis in a patient with relatively normal calcaneal morphology is a far more straight forward prospect.

An Atkins incision is used, its horizontal limb along the junction of the plantar(2) and dorsal skin and the vertical incision passing quite posteriorly up to the lateral border of the Achilles tendon 6 cm proximal to the upper border of the calcaneum.The peroneal tendons(1) have also been marked off.

The skin incision is made along the line of the premarked incision, from the base of the 5th metatarsal to 6cm proximal to the superior border of the calcaneum abutting the lateral margin of the achilles.The peroneal artery and sural nerve are contained in the upper anterior flap. The skin incision should be full thickness and one should avoid undermining the edges, which can devascularise the skin and cause wound breakdown.

Once the initial incision is made it is helpful to retract the anterior flap using cats-paws or skin hooks.
This allows visualisation of the lateral calcaneum and some tension to aid deep dissection. Great care should be taken to avoid traumatising the skin edges here which could increase the risk of wound breakdown. The plane between the periosteum and the lateral calcaneum is then developed.

Careful sub periosteal dissection sticking to bone assistant should ensure tension is maintained on the anterior flap.The extended lateral approach flap is elevated using a combination of sharp dissection and periosteal elevator.
Take care to avoid damage to the Achilles tendon in the proximal portion of the wound, by dissecting carefully through the superficial fascia, (it really helps to have an assistant provide controlled retraction, which allows the superficial layer to separate as it is incised), exposing the paratenon and underlying achilles.
The peroneal tendons are elevated with the anterior flap, sticking to the bone dissecting the periosteum off the lateral wall of the calcaneum helps create a thick flap, and avoids skirting off more deeply and injuring the tendons.
Particular care should be taken around the peroneal tubercle, where both tendons are closely opposed and adherent to the calcaneum.

Dissection is advanced and the tip of the fibula is exposed at the proximal portion of the flap.Once the peroneal tubercle is exposed, dissection is advanced towards the fibula.
The CFL is usually found emerging from the lateral wall and passing towards the fibula tip, this should be elevated off the bone and as this is traced upwards, the fibula is exposed. Careful dissection of the soft tissues off the tip of the fibula exposes enough room to pass a wire to retract the flap superiorly/ proximally.
The lateral wall of the calcaneum can now be assessed. The wall maybe be significantly lateralized after a calcaneal fracture, causing widening of the heel (making footwear difficult). The subtalar joint is often obscured. In either of these scenarios, the lateral wall may need to be osteotomised and excised.

The prominent lateral wall is excised parallel to the lateral wall of the calcaneal tuberosity.Sufficient bone should be excised to address the sub fibular impingement, debriding the lateral wall so it is not prominent beyond the overhang of the lateral talar process.
It is vital at this stage to have located 3 points of reference, the tip of the fibula that has already been exposed, the lateral process of talus and the calcaneo-cuboid joint (in this case the lateral wall of cuboid as the anterior process is so fragmented it cannot be relied upon as a reliable anatomic reference) .
The wall should not be excised more medially than any of these 3 points. Careful assessment of the CT scans should be made to ensure that if a generous lateral wall exostectomy is performed, sufficient calcaneal bone stock will be left to maintain the integrity of the calcaneum.

The lateral wall exostectomy can be progressed It is sensible to start with a thin layer and remove subsequent slivers until the required contour is achieved and the subtalar joint is exposed.

The exostectomy is completed using an osteotome and bone rongeurs, in order to avoid injury to the peroneal tendons distally as they traverse the anterior process and calcaneo-cuboid joint.

The lateral calacaneum should then be assessed to ensure that access to the subtalar joint is adequate, that the subfibular impingement has been resolved and heel width is acceptable.
Bone from the lateral wall is removed and can be saved for bone graft.

The subtalar joint is now exposed and distracted..If the subtalar joint is not yet visible, continue the dissection of the anterior flap elevating it with the peroneal tendons to expose the anterior and posterior aspect of the subtalar joint and the tip of the fibula. Again keeping close to bone, using sharp dissection with an assistant retracting the flap is advisable. The peroneal tendons will traverse the distal wound over the distal calcaneum and calcaneocuboid joint and should be protected.
If exposure is challenging then two broad K wires can be inserted into the tip of the fibula and used as retractors for the anterior flap if they are bent upwards. The tip of the fibula should be exposed to avoid skewering the peroneal tendons with the wires, which are passed longitudinally along the axis of the fibula.

In this particular case as there is a large void/ bone defect due to non-union of the anterior process of the calcaneum. The Ultos plate is used as a bridging between the more proximal calcaneum and the cuboid, as an augment to the longitudinal stabilising screw. I use the orthosolutions Ultos plate as it is low profile and has multiple options for locking and non-locking screws.
The screws are passed using the drill guides, through the plate into good quality bone in the calcaneal body, and into the cuboid.

The talonavicular joint is reduced and temporarily fixed. With the heel and subtalar already temporarily reduced, the talonavicular joint can be orientated to correct foot abduction/adduction, and supination/pronation.Temporary fixation of the Talonavicular joint is now achieved using the guidewires for the cannulated screw system. A small incision is made just distal to the medial navicular tuberosity between the tibialis posterior insertion and the dorsally lying tibialis anterior.
Using a McIndoes scissors, blunt dissect down onto the distal facet of the navicular tuberosity, (the prominence of this facet can usually be appreciated by running the thumb along the medial cuneiform; proximally the distal navicular is felt to protrude medially)
The wire is passed under I.I guidance and on the lateral view should pass centrally down the talar neck, penetrating neither the ankle nor the subtalar joint.

A guidewire is passed at a 30° angle passing into the medial 1/3 of the navicular and entering the talar head centrally.
Passing the wire too shallowly risks fracturing the medial tuberosity,. Passing it too laterally angulated may not engage sufficient talar head.
The guidewire should be passed to a point 1cm or so beyond the junction of the neck and body of the talus. the screw does not need to be passed deeper, and doing so can compromise optimal positioning of the subtalar screws.
Once the wire location has been checked on image intensifier, the depth is read off the depth gauge and 10mm is subtracted for the screw length. A 5mm cannulated drill is passed over the wire stopping just shy of the tip. It is helpful to have an unmounted wire at hand, the guidewire frequently comes out with the drill, and the spare wire can be passed swiftly down the drill hole so as not to lose position.
I have used a 6.5mm orthosolutions cannulated partially threaded cancellous screw here. the screw is inserted, whilst the talonavicular joint is observed, ensuring good compression and joint apposition. As the screw head approaches the navicular, it is very important to tighten in slow controlled manner, as overzealous tightening can lead to fracture of the tuberosity or over penetration through the bone.

The lateral Image intensifier view shows the calcaneocuboid joint and anterior process of the calcaneum have been fixed with a longitudinal screw without compression and an Ultos, bridging plate. The talonavicular screw could have been positioned slightly more plantarly.
The two subtalar screws are parallel to and and the threads traverse the posterior facet. The dosrsiflexed alignment of the talus has been improved.

Once sufficient bone is excised, the subtalar joint can be visualised. Identifying the subtalar joint is relatively straight forward, sometimes the joint space is evident, articular cartilage of the posterior facet is usually seen.
Varus/valgus stressing of the calcaneum may show movement. Occasionally with a tight joint, exposing the sinus tarsi and placing a laminar spreader and distracting the joint opens making it more accessible.
As the lateral wall is excised, the fibula tip (1) can be clearly identified superiorly with adequate clearance from the calcaneum inferiorly.

Rongeurs are used to clear the sinus tarsi of fat and scar tissue.This allows improved visualisation of the subtalar joint and begins to allow access for joint preparation.

Continue to clear the sinus tarsi and lateral subtalar joint with a combination of rongeurs and sharp dissection, until the joint can be opened (1) and will accept a laminar spreader.

A laminar spreader is placed into the sinus tarsi and opened. I use a toothed spreader which is less likely to slide out. Laminar spreaders have a habit of springing loose, so tying a large gauze swab around the frame of the spreader and fixing the swab to the drapes with a mosquito is a really useful tip in preventing the spreader from springing off the table.
Initially the joints can be tight and once the interosseous ligaments are placed under tension by the spreader, these can be divided sequentially across the joint using a scalpel or dissection scissors which allows further distraction.
Avoid deep penetration with scalpel or scissors, as the neurovascular bundle is at risk medially.

Once the joint is opened, a reasonable view of the lateral half of the posterior facet(1), the anterior facet(2) should be obtained.

Joint preparation can begin once the subtalar joint is exposed.Once adequate visualisation is achieved the cartilage and subchondral bone should be carefully cleared using a sharp chisel.
The calcaneal side is more easily cleared. The posterior facet maybe plantarflexed in post calcaneal fracture cases, and needs to be cleared out in its entirety. The talus has a concave alignment and the cartilage and subchondral bone need to be carefully cleared towards the medial side.
When approaching the medial aspect of the posterior facet, the chisel has a more perpendicular orientation to the joint surface . Here taking small wedges of cartilage and bone in a stepwise fashion producing a “fish-scale” or “tiled” effect is helpful. Avoid penetrating too deeply with the chisel as this will risk fracturing the medial side of the talus.

once the lateral side of the joint is prepared, the medial joint is exposed and preparedThe laminar spreader is repositioned and placed more deeply, allowing visualisation of the middle facet.
The medial side of the posterior facet must be carefully cleared. The flexor hallucis longus tendon and the tibial nerve lie adjacent to the posteromedial joint and are at risk of iatrogenic injury from over zealous penetration of a sharp chisel, especially inferiorly.
A back cutting, spinal rongeurs should be used to clear the medial aspect of the joint. Access is best achieved posteriorly, where it can gently pushed out of the joint then pulled back onto bone. The jaws are then carefully worked anteriorly, in a step-wise fashion, removing small bites from the talar and calcaneal surfaces ensuring that the deep part of the jaw is always pulled onto the bone. After each cut the medial joint is inspected, seeking to see if the FHL tendon has become exposed.

The medial joint is cleared until the joint is moves freely and the FHL tendon can be visualised, which confirms that the breadth of the joint has been prepared. The tendon, which passes somewhat more obliquely than one might expect, can be seen to move with flexion and extension of the hallux.
The FHL tendon passes from proximal to distal, just lateral to the posterior talar process, passing across the postero-medial aspect of the subtalar joint before passing below the sustentaculum. Deep to the FHL is the tibial nerve and the posterior tibial artery.
Not all surgeons look to expose the FHL, and the key point is that the joint has been fully mobilised, there are no prominent edges or surfaces that may impede joint positioning/reduction, and that good subchondral bone has been exposed.

The anterior and middle facets are prepared with sharp chisels.The posterior facet is adequately denuded of cartilage and subchondral bone, so that punctate areas of bleeding and a wide area of good quality cancellous bone is exposed.
Next attention should be turned to the anterior facet. Using a sharp chisel, the cartilage and subchondral bone should be removed from the plantar aspect of the talar head and the dorsal surface of the calcaneum to expose bleeding bone.
Ensure that 3 or 4mm of the inferior margin of the talar head and of superior surface of the anterior process are removed, so that compression is not compromised later in the operation.

Finally the middle facet is exposed(1) and similarly cleared. This allows a broad surface area of exposed subchondral bone across the subtalar join to achieve union.

The articular surfaces are prepared with a thick K-wire and chisels. Once cartilage and subchondral bone have been removed the joint surfaces should be prepared using a guide wire to puncture the subchondral plate. A short wire is drilled at intervals of 4 mm apart and the assistant should irrigate the wire with saline to prevent thermal damage to the bone.

The calcaneal surface is similarly prepared with a thick K wire passed 4 mm apart and 5 mm deep.

The surface is further petallised using a chisel and joining the pre-drilled wire holes the chisel is passed 5 mm deep with a slight twisting action to loosen the surface the process is repeated across both the talar and calcaneal surfaces.

The calcaneo-cuboid joint is approached through the distal portion of the lateral incision, here it is well visualised due to the degree of bone loss in the anteror process.A sharp chisel and currettes are used to remove remaining cartilage to expose punctate bleeding bone and a good surface area of healthy cancellous bone.
The joint surfaces are petallised with a 2mm k wire and a sharp chisel. The exposure of the cuboid here is easy given the void in the anterior process, in situations where the anterior process is preserved, it is important to prepare the medial 1/3 of the joint, as due to its saddle shaped configuration this can be neglected.
A wire distractor across the joint will help with visualisation, and preparation should progress with purposeful progressive clearance following the contour of the bone. We find preparation of the medial and plantar joint can be aided with use of a back-cutting rongeur.

Next the talonavicular joint is approached through a separate dorsal incision, beginning just proximal to the anterior ankle skin crease, extending 10-15cm distally. the EHL and tibialis anterior tendons should be identified, and the incision should pass along the plane between these 2 tendons.I favour the dorsal approach as it allows an excellent exposure of the entire talonavicular joint,
The medial dorsal cutaneous branch of the superficial peroneal nerve and the anterior cutaneous branch of the saphenous nerve are at risk superficially here.
Once the skin is incised, careful retraction an blunt dissection through the superficial fascia reduces the risk of nerve injury.

The incision is progressed deeply between the EHL and tibialis anterior tendons, The inferior border of the superior extensor retinaculum is usually found in the proximal wound and 1-2 cm of this may need to be incised in line with the incision..The deep peroneal nerve and the dorsalis paedis artery run longitudinally deep and lateral to the EHL tendon towards the 1st /2nd web space they are at risk of injury here.
The EHL tendon along with the neurovascular bundle is retracted with a Langenbeck retractor.
There are a number of transverse vessels running along the capsule that will need to be coagulated with diathermy.

The talonavicular joint is seen and the dorsal surfaces of talus and navicular exposed.Once the plane between EHL and tibialis anterior has been developed the dorsal capsule of the talonavicular joint is exposed. This is incised and a subperiosteal dissection of the deep tissues of the talar neck and the navicular is developed both medially and laterally. Again care should be taken to avoid injury to the deep peroneal nerve and the dorsalis pedis artery, diathermy to transverse vessels may be needed here.
Sometimes the talonavicular joint can be quite obscured if there is a large dorsal osteophyte and this osteophyte may need to be removed in order to expose the joint. It can be helpful to confirm the location of the joint with an image intensifier, as the naviculo-cuneiform joints can have a similar orientation and can be exposed in error.

The dorsal talar articular surface is exposed with gentle plantarflexion of the foot and joint preparation is commenced.The exposed articular surface of the talus is carefully removed using a sharp chisel(1). Underneath the hard subchondral bone the talar head becomes very soft and the cartilage and bone should be removed in a controlled manner ensuring that not too much bone is excised here, which is quite easy to do. Exposure is helped by passing a ring handled spike(2) or Homans retractor medially and laterally adjacent to the navicular.

Exposure of the deeper articular surface of the talus and the navicular is best achieved by distraction of the joint using a a wire distractor such as a Hintermann.A 1.6 mm wire is passed from dorsal to plantar through the navicular taking care not to penetrate the articular surface which is often more concave than expected.
A second wire is subsequently passed parallel into the talar neck. These two wires enable the application of a Hintermann rectractor, which allows easy distraction of the joint for further preaparation.

I find that a standard laminar spreader has a tendency to cut into the exposed cancellous surface, specifically of the talus.
A second, roughly parallel wire is also passed into the talar head, then allowing a Hintermann distractor is passed over the wires
These wires are folded over as shown to ensure good apposition of the distractor to the bone. The distractor is then slowly opened to expose the joint. Further release of the capsule may be required here expose the joint optimally. The wires can cut out of the bone so gentle progressive distraction in association with progressive capsular release is better here.

The articular surfaces of the navicular and plantar talus are prepared using a sharp chisel, the cartilage and bone are removed in small increments, taking care to remove minimal bone stock especially from the talar head.
Failure to observe this will lead to difficulty achieving a stable reduction, and good bone contact for the fusion.

The navicular preparation can be challenging due to its concave nature.
The chisel addresses the plantar and medial articular surface slightly more perpendicular so penetrating the chisel to shallow depths and removing small wedges cartilage and bone at a time, a process called “fish-scaling” or “tiling”, prevents removing big chunks of bone, or worse, a fracture plantar and lateral aspect of the navicular.

Once the cartilage and subchondral bone have been removed the articular surface is prepared using a large K wire penetrating to a depth of 5 mm with 4 mm gaps in between in a “pepper-pot” configuration across the navicular.

The talar head is prepared again using a thick a wire penetrating 5 mm deep 4 mm spacing, pepper-potting the talar head

The articular surfaces of petallised using a thick chiselThe pre-drilled holes are joined with a chisel which is inserted and gently twisted to produce good exposed cancellous bone.
Preparing the joints as such will optimise coaptation and bony contact across the fusion surface.

Prior to definitive fixation, Each of the joints should be corrected and temporarily fixed with the wires from the cannulated screw system.The subtalar joint should be fixed to address the heel varus /valgus, to increase talar declination as needed, and to a degree of abduction/adduction.
The talonavicular can correct foot ab/adduction and supination/pronation.
The calcaneocuboid helps fine tune the orientation of the lateral column relative to the medial column.
An image intensifier should be used to check the placement of all the wires and to confirm satisfactory reduction.
For ease of interpretation, in this operative description, the preparation and fixation of each joint is described sequentially in the next part of the technique. However in reality, at each step of fixation the adjacent joints are carefully cross referenced; often fixation will be alternated between joints before secondary screws and plates are applied, in order to gain stability. and maintain reduction.

A 4cm longitudinal incision is made in the posterior inferior heel extending distally to the juntion of plantar and dorsal skin through which guidewires and subtalar screws will be passed.Prior to passage of the temporary fixation wires from the orthosolutions 8mm cannulated screw system, the heel needs to be reduced to physiological valgus.
For severe malunions an additional osteotomy of the calcaneal tuberosity may be required to align the heel adequately.
Especially in cases of deformity, preparation of all 3 triple joints prior to temporary fixation is advisable, this allows a greater freedom of multi-level correction in all 3 planes .

The guide wire for the cannulated screws is now passed from the tuberosity of the calcaneum aiming to pass through the middle of the posterior subtalar facet
The wire should be aimed slightly medially and towards the anterior border of the tibial plafond. It is helpful to screen the passage of the wire regularly to avoid penetration through the talar neck or into the ankle joint. If two wires are going to be passed across the posterior facet, one should be placed slightly more posteriorly and the other slightly more anteriorly.
Sufficient space should be left between the wires so that both screws can be snugged down onto the calcaneal tuberosity with an intervening bridge of bone.

Two wires can be seen passing into the Posterior facet of the talus (1)
Given the large defect in the anterior process and bone void in this case, a third wire is passed longitudinally parallel to the plantar border of the calcaneum and into the cuboid bone(2).

In this, slightly atypical, case there is significant bone loss in the anterior process of the calcaneum as can be seen on the CT scans. A femoral head will be used to fill the large bony voids.
The allograft femoral head is prepared by removing cartilage and subchondral bone with a saw and bone cutter.
With smaller defects we would tend to use autologous graft from the iliac blade. Given the large voids in this particular case, a femoral head was used, as we felt iliac graft would not have filled the defects.

Once the femoral head is prepared it is ready for milling.

The femoral head is placed in a bone-mill and plunged onto the blades which are manually rotated resulting in a copious supply of morsellized bone chips.

Bone fom the lateral wall can be added to the mill, and the chips soaked in bone marrow aspirate.

In this case the large voids are packed with the previously milled bone graft and impacted tightly using a bone punch.

Once the bone graft is firmly impacted into the bone voids fixation can commence.
Direct bone contact is achievable over a proportion of the joint, the bone graft is packed into the remaining voids. In this case, compression is not possible over the comminuted non-united anterior process, and calcaneo-cuboid joint will need to be bridged to provide stability.

The calcaneal guide wires (1) are measured using the Orthosolutions depth gauge.
Routinely 10 mm is subtracted from the reading to determine the length of the 8 mm cancellous screw that will be selected.

One or two large fragment 8mm diameter OrthoSolutions screws, with a 32mm thread are used to fix the subtalar joint.

The 5mm drill is passed over the K-wires, this should be done under image intensification to avoid penetrating the ankle joint.
The orientation of the guide wires and the subsequent screws is from the calcaneal tuberosity inferiorly into the talar body, avoiding penetrating the talar neck superiorly, which is a risk if II is not used.

The screws are inserted in a controlled fashion under II.
Its is important that the heads are recessed into the calcaneus inferiorly, otherwise they will produce local heel pain upon weightbearing.
A longitudinal 8mm orthosolutions cannulated screw is also passed from the calcaneal tuberosity into the cuboid. It should not be compressed. The screw is essentially used to maintain the length of the calcaneum, and to provide some stability. This is then supplemented by a locking plate across the joint.

The anterior proces and calcaneocuboid joint require further stabilisation with a neutralizing plate. here an 8 hole orthosolutions ultos plate is checked for size

A single screw across the talonavicular joint, whilst allowing good compression, confers little rotational stability.
Further fixation with a plate, staple or second screw improves stability at the arthrodesis site.
For this I use a Wright claw plate. There are a number of options but I tend to use the 2 hole plate, there is little room in the talar neck for more screws.

The correct sized plate is presented to the dorsal surface, the plate should be long enough to traverse the joint but not too long, that it impinges on the anterior ankle or the naviculo-cuneiform joints. Once the appropriate size is selected it should be applied to the dorsal surface, if it doesn’t sit well, it is possible to contour the dorsal bone surface with rongeurs or a chisel, or to bend the plate until a snug fit is achieved.
The guide chimney is screwed into the threads of the plate and the screw holes are drilled through the guide chimney, these should aim to miss the longitudinal screw and pass through the talar neck, ensuring that it doesn’t penetrate into the subtalar joint(more important in an isolated talonavicular fusion). The distal screw should pass through the body of the navicular and not penetrate the navicular joints distally or proximally.

the screw holes are drilled through the guide chimney and can be measured from the drill or using the depth gauge as shown here. The screw length is the same as the absolute measurement.

Once the screws are inserted, the plate is compressed with the compression device.
This step is not shown, but involves the insertion of a pair of pliers into the central point of the staple and distracting the parallel limbs of the staple to produce compression through the screws fixed at either end.

The Charlotte claw plate is compressed: the compression device is inserted into the slot on the plate, once it is firmly engaged, the arms of the device are squeezed firmly the slot is seen to expand by a few mm.Expanding the plate has the effect of reducing the distance between the distal and proximal screws which results in compression. If the screw engages both cortices the compression is more uniform across the joint.

The soft tissue envelope is closed in multiple layers. interrupted 1 vicryl sutures can be used to close the deep fascia adjacent to the bone.

The superficial fascia is opposed and closed with interrupted dissolvable, braided 2/0 vicryl sutures.
The wound is closed with an interrupted 3/0 nylon mattress suture.

After dressing the wounds with adhesive dry dressings and gauze, a below knee back slab is applied the ankle held at 90° it is important to maintain the position while the back slab sets. It’s helpful to flex the knee to achieve a plantigrade position.

Post operative CT scan confirms bony union across the subtalar and talonavicular joints.

Post-operative axial CT scan at 12 weeks shows bony union across the anterior process and calcaneo-cuboid joint.

Post-operative Coronal CT scan shows that the lateral wall prominence, and sub-fubular impingement has been addressed.