Revision of Malunion and Nonunion After Hindfoot Arthrodesis

Hindfoot arthrodesis is a powerful tool for the correction of severe pain and deformity in the foot and ankle; however, these procedures can result in nonunions or malunions which pose significant reconstruction challenges, with little evidence to guide treatment. Evaluation begins with a detailed history and physical, focusing on understanding the initial reason for arthrodesis and patient risk factors that may compromise healing. The patient’s medical status should be optimized prior to proceeding with revision. Imaging includes standard foot and ankle series, and advanced imaging with CT scanning is almost always necessary. The goal of reconstruction of a failed hindfoot arthrodesis is to achieve a plantigrade foot with solid union. Success can be achieved by restoring the normal anatomic and radiographic relationships of the hindfoot, midfoot, and forefoot. A variety of surgical techniques have been described. Regardless of technique, apposition of healthy bone ends with application of bone graft and rigid internal fixation are necessary for maintenance of deformity correction and solid fusion. After hindfoot correction, other deformities in the midfoot or forefoot may be unmasked. Additional procedures in the midfoot and forefoot may be needed to ensure that all deformity is addressed to achieve a plantigrade foot.