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Patients › Foot

Subtalar fusion

PDF Evidence Consent
Updated Sep 2026
Illustration: foot

Why this operation has been suggested

Subtalar fusion is an option when the joint itself is the source of your pain. The subtalar joint sits below your ankle and lets your foot tilt and turn on uneven ground. Fusion, also called arthrodesis, means joining the bones of that joint together so they no longer rub on each other. Once the bones heal as one solid piece, the painful movement stops.

We usually suggest this operation for ongoing arthritis after a heel fracture, for painful flatfoot caused by a joint that never formed properly, or for a heel that has healed in a poor position. Because this is often a long-standing problem, we start with non-operative care such as activity change, physiotherapy, splinting or a brace, and we consider surgery when that has not given enough improvement. The aim is a stable, pain-free foot so you can walk and stand comfortably again.

Before the operation

To plan your operation, we arrange scans of your foot. These may include weight-bearing X-rays, where you stand while the pictures are taken, and sometimes a CT scan, which shows bone in fine detail, or an MRI, which shows soft tissues such as tendons and ligaments. You will get instructions about fasting from our team: no food or drink for seven hours before surgery. We ask for seven rather than six so that your operation can be brought forward if the theatre list runs early. Stop taking certain medications only if we tell you to; bring a written list of everything you take, including tablets and natural remedies. Wear loose, comfortable clothing and arrange a lift home, as you will not be able to drive yourself. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic.

On the day

You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who gives your anaesthetic. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed.

You wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either move to a ward or go home, depending on the procedure and how your recovery is going. Some subtalar fusion operations are done on a day-surgery basis, so you may not need to stay overnight. Our team will let you know what to expect for your operation.

What the operation involves

Subtalar fusion joins the bones of your subtalar joint together so they heal as one solid piece. To do this, your surgeon removes the remaining smooth cartilage from the joint surfaces, the worn-out tissue that has been causing pain. The bones are then held together with screws while they heal. Sometimes a bone graft, extra bone material that helps the two surfaces knit, is placed between them.

There is more than one way to reach the joint. Some operations use one cut on the outer side of your foot. Others use keyhole surgery, where the surgeon works through two or three small cuts instead of one larger opening. The choice depends on your foot, your scans, and whether the joint can be moved into a good position. If your ankle joint is also worn out, the operation can be extended to join the ankle and heel bone together as well, using a rod that runs down through the ankle into the heel.

Your surgeon will explain which approach suits you before you sign the consent form.

After the operation

You wake up in the recovery ward, where nurses keep a close eye on you while the anaesthetic wears off. Your foot will be in dressings, and we give you pain relief to keep you comfortable. A nurse will check your wound, your circulation, and how you are feeling before you get up. Most people take a few steps with a frame or crutches on the same day, with help from our team. Because the anaesthetic can make you drowsy and unsteady, please arrange for someone to stay with you for the first 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you.

Recovery

Your foot will be sore and swollen for the first days and weeks. This is normal. Rest, keeping your foot raised, and the pain relief we give you will ease the discomfort. The swelling usually settles gradually, and the soreness eases as the bones begin to knit.

You will not put your full weight on the foot at first. You will use crutches or a frame to get around, and your foot will be protected in a cast or boot while the bones heal. Your physiotherapist will guide you through simple exercises to keep the rest of your leg strong and your circulation moving. You can move around the house, prepare meals, and manage stairs with care, but you will need help with some daily tasks early on. Sleeping with your foot raised on pillows can reduce swelling and make nights more comfortable.

The first big milestone is when we see you and your wounds have healed. As healing progresses, you will move from crutches to walking on the foot, first with support and then without. Once the bones have joined as one solid piece and your surgeon is happy with how they have healed, you can build up your activity. Walking further, returning to work, and getting back to sport all come in stages as your strength and confidence return.

Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you at each step.

What can go wrong

Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.

The most common worry after this operation is the wound. Watch for redness that spreads out from the cut, fluid or pus leaking from it, or skin that feels hot and looks angry. A deep, throbbing pain that does not ease with simple painkillers is another warning sign. If you notice any of these, call the clinic straight away rather than waiting for your next visit.

Sometimes the bones do not knit together as planned. This is called nonunion. You might feel a grinding or clicking in the foot, or pain that keeps returning months after surgery instead of fading. Bring this up at your review appointment so we can arrange scans and talk about what to do next.

If your operation also joins the ankle and heel bone together, the metal rod or screws can occasionally cause irritation or a break in the bone around them. This usually feels like new pain, a change in how the foot feels under you, or a sudden clunk followed by trouble putting weight on the leg. Contact the clinic promptly if this happens.

With some foot shapes and previous injuries, the skin and soft tissues around the heel can be fragile. Your surgeon chooses the approach, meaning where the cuts are made, with this in mind, to give the wound the best chance of healing cleanly. If you have concerns about how your wound looks during those first weeks, we want to hear about it.

In a small number of complex cases, particularly where a foot has severe deformity or poor healing, further surgery can be needed to sort the problem out. Your surgeon will discuss this with you beforehand if it applies to your foot.

The complications table on this page lists typical rates if you want the specifics.

When to call us

Most problems show up in the first weeks, and early treatment makes them easier to sort out. Call us if you develop a fever, if the redness around your wound spreads, or if fluid or pus leaks from it. Call us if you have sudden severe pain that simple painkillers do not touch. Go to emergency if you have swelling or pain in your calf, or shortness of breath, as these can be signs of a blood clot. Go to emergency if your foot becomes numb, cold, or you cannot move your toes. When in doubt, call the clinic. We would rather hear about a small worry than have you sit on a big one.

Reviewed by AI synthesis (v2) — pending human review · 9 September 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology

Bony Anatomy

  • The ankle joint includes the tibia, talus, and fibula [2].
  • The talar dome is biconcave with a central talar sulcus [2].
  • The radius of curvature of the talar dome is greater laterally [2].
  • The talus features an anterior calcaneal surface, a posterior calcaneal surface, and a middle calcaneal surface [7].
  • The talus features an articular surface for the navicular and an articular surface for the calcaneonavicular ligament [7].
  • The talus features a groove for the flexor hallucis longus tendon [7].
  • The talus features a medial tubercle and a lateral tubercle [7].
  • The talus features an articular surface for the medial malleolus and an articular surface for the lateral malleolus [7].
  • The talus features an articular surface with the distal end of the tibia [7].
  • The talus features a sulcus tali [7].
  • The foot bones include the talus, navicular, cuneiform bones, cuboid, first metatarsal bone, fifth metatarsal bone, and calcaneus [10].
  • The foot possesses a transverse arch [10].

Ligaments

  • The deltoid ligament is composed of two layers [7].
  • The superficial layer of the deltoid ligament includes the tibionavicular and tibiocalcaneal ligaments [7].
  • The superficial layer of the deltoid ligament crosses both the ankle and subtalar joints [7].
  • The deep layer of the deltoid ligament includes the anterior and posterior tibiotalar ligaments [7].
  • The deep layer of the deltoid ligament crosses only the ankle joint [7].
  • The lateral fibular ligaments include the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL) [7].
  • The ATFL is the weakest of the lateral ligaments and is intracapsular [7].
  • The ATFL is most commonly injured with a lateral ankle sprain [7].
  • The CFL crosses both the ankle and the subtalar joint [7].
  • Plantar flexion tightens the ATFL [7].
  • Inversion with neutral flexion tightens the CFL [7].
  • The interosseous talocalcaneal ligament is also known as the cervical ligament [10].
  • The interosseous talocalcaneal ligament attaches proximally to the talus and distally to the calcaneus [10].
  • The calcaneocuboid/calcaneonavicular ligament is also known as the bifurcate ligament [10].
  • The bifurcate ligament attaches proximally to the calcaneus and distally to the cuboid and navicular [10].
  • The calcaneocuboid-metatarsal ligament is also known as the long plantar ligament [10].
  • The long plantar ligament attaches proximally to the calcaneus and distally to the cuboid and first to fifth metatarsals [10].
  • The plantar calcaneocuboid ligament is also known as the short plantar ligament [10].
  • The short plantar ligament attaches proximally to the calcaneus and distally to the cuboid [10].
  • The plantar calcaneonavicular ligament is also known as the spring ligament [10].
  • The spring ligament attaches proximally to the sustentaculum tali and distally to the navicular [10].
  • The tarsometatarsal ligament is also known as the Lisfranc ligament [10].
  • The Lisfranc ligament attaches proximally to the medial cuneiform and distally to the base of the second metatarsal [10].
  • The tibionavicular ligament attaches proximally to the medial malleolus and distally to the navicular tuberosity [10].
  • The tibionavicular ligament limits talar external rotation [10].
  • The tibiocalcaneal ligament attaches proximally to the medial malleolus and distally to the sustentaculum tali [10].
  • The tibiocalcaneal ligament limits hindfoot eversion [10].
  • The anterior tibiotalar ligament attaches proximally to the medial malleolus and distally to the medial surface of the talus [10].
  • The anterior tibiotalar ligament limits lateral displacement of the talus and external rotation [10].
  • The posterior tibiotalar ligament attaches proximally to the medial malleolus and distally to the inner side of the talus [10].
  • The posterior tibiotalar ligament limits lateral displacement [10].
  • The anterior talofibular ligament attaches proximally to the lateral malleolus and distally transversely to the talus anteriorly [10].
  • The anterior talofibular ligament limits inversion in plantar flexion [10].
  • The calcaneofibular ligament attaches proximally to the lateral malleolus and distally obliquely to the calcaneus posteriorly [10].
  • The calcaneofibular ligament limits inversion in neutral or dorsiflexion [10].
  • The posterior talofibular ligament attaches proximally to the lateral malleolus and distally transversely to the talus posteriorly [10].
  • The posterior talofibular ligament limits posterior talus displacement and external rotation [10].

Neurovascular Anatomy

  • The tarsal tunnel is a fibroosseous tunnel within the posteromedial ankle and hindfoot [3].
  • The tibial nerve, posterior tibial artery, accompanying veins, posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus tendons pass through the tarsal tunnel into the foot [3].
  • The flexor retinaculum acts as the roof of the tarsal tunnel [3].
  • The flexor retinaculum extends from the medial malleolus to the medial side of the calcaneal tuberosity [3].
  • The medial distal tibia, talus, and calcaneus make up the floor of the tarsal tunnel [3].
  • Septa projecting from the fibrous roof to the calcaneus separate the posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons [3].
  • The tibial nerve divides into three terminal branches before reaching the foot: the medial calcaneal nerve (MCN), lateral plantar nerve (LPN), and medial plantar nerve (MPN) [3].
  • The tibial nerve typically branches within the tarsal tunnel just proximal and deep to the upper edge of the abductor hallucis muscle [3].
  • The MCN branches first from the tibial nerve and travels posteriorly to the subcutaneous tissue [3].
  • The LPN passes under the abductor hallucis, over the medial fascia of the quadratus plantae, deep to the plantar fascia, and under the heel to the flexor digitorum brevis [3].
  • The LPN terminates in the fourth web space and supplies a branch to the third web space [3].
  • The LPN supplies motor branches to the intrinsic muscles [3].
  • The MPN innervates the abductor hallucis and continues under the abductor and plantar fascia to form common digital nerves [3].
  • The common digital nerves from the MPN terminate in the first, second, and third web spaces [3].
  • The MPN supplies motor branches to the interossei and lumbricals [3].
  • The dorsalis pedis artery is a continuation of the anterior tibial artery that passes deep under the inferior extensor retinaculum [4].
  • As the dorsalis pedis artery passes anterior to the ankle joint, it lies between the tendons of the extensor hallucis longus medially and the extensor digitorum longus laterally [4].
  • The deep peroneal nerve lies immediately lateral to the dorsalis pedis artery [4].
  • The dorsalis pedis artery gives off medial and lateral tarsal arteries as it passes over the tarsal bones [4].
  • The arcuate artery arises from the dorsalis pedis artery in the region of the bases of the metatarsals and passes laterally [4].
  • The second, third, and fourth dorsal metatarsal arteries arise from the arcuate artery [4].
  • The first dorsal metatarsal artery is the continuation of the dorsalis pedis artery [4].
  • The first dorsal metatarsal artery runs distally on the dorsal surface of the first dorsal interosseous muscle [4].
  • The deep plantar, or communicating, artery leaves the dorsalis pedis at the base of the first metatarsal [4].
  • The deep plantar artery passes toward the plantar surface of the foot between the heads of the first dorsal interosseous muscle [4].
  • The deep plantar artery communicates with the lateral plantar artery to complete the plantar arterial arch [4].
  • The first dorsal metatarsal artery may lie superficial to or within the substance of the first dorsal interosseous muscle in 78% to 88% of feet [4].
  • The first dorsal metatarsal artery may lie plantar to the first metatarsal in 12% to 22% of feet [4].
  • The diameter of the dorsalis pedis artery may range from 1.8 to 3 mm [4].
  • The venous drainage from the dorsum of the toes and foot flows into the dorsal venous arches, feeding the greater and lesser saphenous systems [4].
  • The dorsal surfaces of the toes and foot receive sensory innervation through branches of the superficial peroneal nerve [4].
  • The first web space is innervated by the deep peroneal nerve [4].
  • The plantar surface of the foot is innervated by the digital branches of the medial plantar nerve [4].

Muscular Anatomy

  • The major tendons crossing the anterior ankle joint, from lateral to medial, are peroneus tertius, extensor digitorum longus (EDL), extensor hallucis longus (EHL), and tibialis anterior [10].
  • The major tendons crossing the medial ankle joint are tibialis posterior, flexor digitorum longus, and flexor hallucis longus [10].
  • The major tendons crossing the lateral ankle joint are the peroneal tendons, with peroneus longus superficial and peroneus brevis deep [10].
  • The peroneus longus inserts on the plantar aspect of the medial cuneiform and base of the first metatarsal [10].
  • The peroneus longus tendon is located posterior and lateral to the peroneus brevis tendon behind the fibula [10].
  • The peroneus brevis has a low-lying muscle belly compared to the peroneus longus [10].
  • The peroneus brevis inserts on the lateral aspect of the base of the fifth metatarsal [10].
  • At the level of the peroneal tubercle, the peroneus brevis lies dorsal to the peroneus longus [10].
  • The Achilles tendon has a maximum anteroposterior dimension of 8 mm on MRI [10].
  • The extensor digitorum brevis (EDB) is the only dorsal intrinsic muscle of the foot [10].
  • The EDB is innervated by the lateral terminal branch of the deep peroneal nerve [10].
  • Plantar heel spurs originate in the flexor digitorum brevis [10].
  • The flexor digitorum brevis is innervated by the medial plantar nerve [10].
  • Lumbrical muscles are located plantar to the transverse metatarsal ligament [10].
  • Interosseous tendons are located dorsal to the transverse metatarsal ligament [10].
  • The tibialis anterior originates from the lateral tibia and inserts on the medial cuneiform and first metatarsal [7].
  • The tibialis anterior acts to dorsiflex and invert the foot [7].
  • The tibialis anterior is innervated by the deep peroneal nerve (L4) [7].
  • The extensor hallucis longus originates from the midfibula and inserts on the distal phalanx of the great toe [7].
  • The extensor hallucis longus acts to dorsiflex and extend the great toe [7].
  • The extensor hallucis longus is innervated by the deep peroneal nerve (L5) [7].
  • The extensor digitorum longus originates from the tibial condyle and fibula and inserts on the middle and distal phalanges of the toes [7].
  • The extensor digitorum longus acts to dorsiflex and extend the toes [7].
  • The extensor digitorum longus is innervated by the deep peroneal nerve (L5) [7].
  • The peroneus tertius originates from the fibula and extensor digitorum longus tendon and inserts on the fifth metatarsal [7].
  • The peroneus tertius acts to evert, dorsiflex, and abduct the foot [7].
  • The peroneus tertius is innervated by the deep peroneal nerve (S1) [7].
  • The peroneus longus originates from the proximal fibula and inserts on the medial cuneiform and first metatarsal [7].
  • The peroneus longus acts to evert, plantar flex, and abduct the foot [7].
  • The peroneus longus is innervated by the superficial peroneal nerve (S1) [7].
  • The peroneus brevis originates from the distal fibula and inserts on the tuberosity of the fifth metatarsal [7].
  • The peroneus brevis acts to evert the foot [7].
  • The peroneus brevis is innervated by the superficial peroneal nerve (S1) [7].
  • The gastrocnemius originates from the posterior medial and lateral femoral condyles and inserts on the calcaneus [7].
  • The gastrocnemius acts to plantar flex the foot [7].
  • The gastrocnemius is innervated by the tibial nerve (S1) [7].
  • The soleus originates from the fibula and tibia and inserts on the calcaneus [7].
  • The soleus acts to plantar flex the foot [7].
  • The soleus is innervated by the tibial nerve (S1) [7].
  • The plantaris originates from the lateral femoral condyle and inserts on the calcaneus [7].
  • The plantaris acts to plantar flex the foot [7].
  • The plantaris is innervated by the tibial nerve (S1) [7].
  • The popliteus originates from the lateral femoral condyle and fibular head and inserts on the proximal tibia [7].
  • The popliteus acts to flex and internally rotate the knee [7].
  • The popliteus is innervated by the tibial nerve (L5, S1) [7].
  • The flexor hallucis longus originates from the fibula and inserts on the distal phalanx of the great toe [7].
  • The flexor hallucis longus acts to plantar flex the great toe [7].
  • The flexor hallucis longus is innervated by the tibial nerve (S1) [7].
  • The flexor digitorum longus originates from the tibia and inserts on the distal phalanges of the second to fifth toes [7].
  • The flexor digitorum longus acts to plantar flex the toes and foot [7].
  • The flexor digitorum longus is innervated by the tibial nerve (S1, S2) [7].
  • The tibialis posterior originates from the tibia, fibula, and interosseous membrane and inserts on the navicular and medial cuneiform [7].
  • The tibialis posterior acts to invert and plantar flex the foot [7].
  • The tibialis posterior is innervated by the tibial nerve (L4, L5) [7].

Pathophysiology

  • Cavus foot is defined as a foot with an abnormally high arch [1].
  • Cavus foot frequently accompanies hindfoot varus deformity, known as cavovarus foot [1].
  • Cavovarus foot may be associated with clawing of the toes and demonstrable weakness of ankle or foot muscles [1].
  • Calluses beneath the metatarsal heads and heel skin are common in cavus foot [1].
  • Hindfoot varus in individuals with a cavovarus deformity is nonstructural if it can be corrected with the "block test" [1].
  • Anterior ankle pain is one of the most common symptoms of cavus foot [1].
  • Anterior ankle pain in cavus foot is sometimes associated with toe walking [1].
  • In cavus foot, the forefoot is severely plantar flexed on the hindfoot, requiring marked ankle dorsiflexion to compensate [1].
  • When cavus deformity becomes too severe, ankle dorsiflexion is blocked, leading to anterior ankle impingement and pain [1].
  • The inability to dorsiflex further in severe cavus foot compromises forefoot clearance, eventually allowing only the metatarsals to contact the floor [1].
  • This condition can be misinterpreted as an ankle plantarflexion contracture, potentially leading to unnecessary heel cord release [1].
  • The cause of cavus foot is usually muscle imbalance in a growing foot [1].

  • Cavus foot is rarely found in early childhood but is fairly frequent after 8–10 years of age [1].

Clinical Presentation

  • Patients with tarsal coalitions often present with a symptomatic flatfoot [22].
  • Pain associated with tarsal coalitions is typically located in the sinus tarsi or along the medial longitudinal arch [22].
  • Limited subtalar motion may present as difficulty with movement on uneven ground [22].
  • Limited subtalar motion may present as frequent ankle sprains [22].

Investigations

Radiographic Evaluation

  • Weight-bearing radiographs are required for the evaluation of pes cavus [21].
  • An increased Meary angle is defined as the long axis of the talus intersecting the long axis of the first metatarsal dorsally on the lateral view of the foot, with a normal value of 0° to 5° [21].
  • An increased calcaneal pitch is defined as the intersection of a line running along the undersurface of the calcaneus and the floor, where a pitch greater than 30° indicates a calcaneocavus foot [21].
  • Medial and lateral oblique projections allow better assessment of the subtalar joint [17].
  • The calcaneum is usually X-rayed in axial and lateral views [17].
  • Weight-bearing X-rays are helpful in showing the coronal relationship of heel to tibia in stance [17].
  • Stress X-rays complement clinical tests for ankle stability and can be carried out under general anaesthesia if stress manoeuvres are painful [17].

Advanced Imaging

  • Computed tomography (CT) scans are important in assessing fractures and for congenital bony coalitions [17].
  • Radio-isotope scanning is excellent for localizing areas of abnormal blood flow or bone remodelling activity, which suggest the presence of covert infection [17].
  • Magnetic resonance imaging (MRI) and ultrasound are used to demonstrate soft-tissue problems, such as tendon and ligament injuries [17].
  • MRI and ultrasound can be used to diagnose joint effusions and bone infections [17].
  • MRI of the spine is indicated with unilateral involvement in pes cavus [21].
  • Diagnosis of cavus foot requires a thorough search for the underlying cause and may require neurologic consultation, spinal MRI, and electromyographic (EMG) studies [1].

Clinical Examination

  • Hindfoot flexibility is assessed by placing a 1-inch block under the lateral border of the foot (Coleman block test) [21].
  • A neurologic examination and a family history are essential for the evaluation of pes cavus [21].
  • Unilateral involvement suggests a focal diagnosis, such as spinal cord anomaly or nerve injury [21].
  • Bilateral involvement and a positive family history are common with Charcot-Marie-Tooth disease [21].
  • The physical examination of the foot and lower extremity begins with the patient standing to note deformities of the toes, such as clawing, a long second ray, or swelling around joints [18].
  • The plantar aspect of the foot is carefully evaluated for evidence of callus formation [18].
  • The metatarsal heads are palpated individually to assess for generalized plantar fat pad atrophy, a prominent fibular condyle, synovitis, or possibly a transfer lesion beneath a metatarsal head resulting from previous forefoot surgery [18].

References

[1] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 10Pediatric Orthopedic Surgery > 4. Cavus Foot.

[2] Aaos Comprehensive Orthopaedic Review 3. Anatomy and Biomechanics of the Foot and Ankle > I. Anatomy.

[3] Campbell S Operative Orthopaedics 4 Volume Set. COMBINED HAMMER TOE AND MALLET TOE DEFORMITY WITH ASSOCIATED DOUBLE CORNS > TARSAL TUNNEL SYNDROME.

[4] Campbell S Operative Orthopaedics 4 Volume Set. RESULTS OF SUTURE OF THE SCIATIC NERVE > NEUROVASCULAR ANATOMY.

[7] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > 2. Arthrology.

[10] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > 2. Arthrology > 3. Muscles.

[17] Apley And Solomon S Concise System Of Orthopaedics And Trauma. CONGENITAL ABNORMALITIES.

[18] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 8Foot and Ankle Surgery > METATARSALGIA.

[21] Aaos Comprehensive Orthopaedic Review 3. Pediatric Foot Conditions > Pes Cavus.

[22] Aaos Comprehensive Orthopaedic Review 3. Pediatric Foot Conditions > Tarsal Coalition.

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d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.