Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

458. Traditional Triple Arthrodesis

Mark E. Easley

DEFINITION

images Triple arthrodesis is a procedure performed to restore and maintain physiologic hindfoot alignment.

images It is typically reserved for:

images Severe fixed deformity not amenable to joint-sparing procedures

images Inflammatory arthropathy of the hindfoot

ANATOMY

images The hindfoot comprises the talus, calcaneus, navicular, and cuboid.

images Physiologic alignment is generally defined as a congruent talar–first metatarsal alignment in both the anteroposterior (AP) and lateral planes with weight bearing.

images The talar–calcaneal articulation is referred to as the subtalar joint.

images The combination of the talonavicular and calcaneocuboid articulations is known as the transverse tarsal joint.

images Multiple ligamentous static restraints support the hindfoot. In fact, in stance phase, the physiologically normal foot is balanced and plantigrade without any dynamic muscle forces acting on it.

images Physiologic hindfoot alignment is influenced by the ankle, midfoot, and forefoot.

images The hindfoot is a component of the ankle–hindfoot complex. To an extent, ankle malalignment can be compensated by the hindfoot.

images The foot is balanced when there is relatively even pressure distribution on the heel, first metatasal–sesamoid complex, and the fifth metatarsal (ie, a plantigrade foot).

images Physiologically normal hindfoot alignment can be distorted by ankle, midfoot, and forefoot deformity.

images While the ankle is primarily responsible for dorsiflexion and plantarflexion, the hindfoot has some capacity to compensate in the sagittal plane with ankle stiffness, as evidenced by residual dorsiflexion and plantarflexion following ankle arthrodesis.

images Ambulation

images With transition from heel strike to stance phase, the hindfoot becomes accommodative to the surface it contacts by “unlocking” the hindfoot joints.

images With push-off, the posterior tibial tendon (PTT) inverts the hindfoot, thereby locking the transverse tarsal joints and hindfoot.

images This converts the foot's accommodative function to one of biomechanical advantage with creation of a rigid lever arm for the Achilles tendon.

PATHOGENESIS AND NATURAL HISTORY

images Hindfoot alignment is easily distorted by imbalance of its dynamic stabilizers, in particular the posterior tibial and peroneal tendons.

images If the imbalance persists and becomes chronic, the hindfoot's static ligamentous restraints may weaken, creating a hindfoot deformity that ultimately may become fixed.

images PTT dysfunction leads to a flatfoot deformity with attenuation of the medial static restraints (spring ligament complex, medial talonavicular capsule) and pes planovalgus (flatfoot) deformity.

images Peroneal tendon dysfunction may lead to lateral ankle–hindfoot attenuation and a pes cavovarus (hindfoot varus) deformity.

images Posttraumatic or inflammatory arthritis may also create a stiff and painful hindfoot, with or without deformity.

PATIENT HISTORY AND PHYSICAL FINDINGS

images The patient typically describes aching in the hindfoot, particularly in the sinus tarsi area, with weight bearing.

images There may be a report of a progressive deformity.

images Stiffness and swelling are common complaints.

images It is important to elicit a history of an inflammatory arthropathy.

images A neurologic and vascular examination is required.

images The patient should be examined while standing and ambulating.

images The deformity may not be obvious with the patient non–weight-bearing.

images Typically the patient will walk with a limp.

images A single limb heel rise for a patient with pes planovalgus deformity, if possible, will determine if the deformity is flexible and if the PTT is functional.

images With the patient seated, range of motion (ROM) is assessed.

images Inversion and eversion are almost always restricted in patients being considered for triple arthrodesis.

images The talus can be stabilized with a thumb on the talar neck to determine dorsiflexion and plantarflexion in the hindfoot.

images Ankle ROM and stability also should be evaluated.

images An equinus contracture may be present and is important when considering surgery. Achilles tendon lengthening may be required to reposition the hindfoot anatomically. Many hindfoot deformities result in Achilles tendon contractures.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Plain radiographs of the weight-bearing foot in the AP, lateral, and oblique views (FIG 1).

images Occasionally, contralateral foot radiographs are useful in understanding what is physiologically normal for an individual.

images I routinely obtain ipsilateral ankle radiographs as well.

images In severe deformity there may be a pre-existing talar tilt.

images If this is the case, proper operative realignment of the hindfoot may be compromised by the more proximal deformity.

images One needs to be aware of pre-existing talar tilt or ankle malalignment to ensure that the hindfoot deformity is corrected appropriately.

images I will check the ankle alignment fluoroscopically while realigning the hindfoot in surgery.

images Rarely is computed tomography or magnetic resonance imaging necessary.

images

FIG 1 • AP and lateral weight-bearing radiographs of patient with posterior tibial tendon dysfunction, spring ligament rupture, and fixed hindfoot deformity. Note severe talonavicular sag visible in B.

NONOPERATIVE MANAGEMENT

images Activity modification

images Nonsteroidal anti-inflammatory agents

images Corticosteroid injection

images Bracing

images Lace-up brace

images Hinged or fixed ankle–foot orthosis

SURGICAL MANAGEMENT

images A spectrum of pathologies may warrant triple arthrodesis:

images Stage III posterior tibial tendinopathy

images Chronic peroneal tendinopathy

images Posttraumatic hindfoot arthritis

images Inflammatory arthritis

images Charcot neuroarthropathy

images Chronic spring ligament rupture

images If a joint-sparing procedure can be performed, it should be favored over triple arthrodesis.

images Selective hindfoot arthrodesis may also be considered.

images There has been a trend toward double arthrodesis in lieu of triple arthrodesis.

images The concept is to preserve the accommodative effect of the calcaneocuboid joint when possible and only perform talonavicular and subtalar joint arthrodeses.

images Isolated talonavicular joint arthrodesis restricts hindfoot motion by 90%.

Preoperative Planning

images The preoperative deformity needs to be assessed to determine what correction is warranted.

images If there is a severe pes planovalgus deformity, consider a single medial approach double arthrodesis to eliminate the risk of lateral wound problems that may occur with a lateral approach in such deformity.

images Equinus contracture: It may be necessary to lengthen the Achilles tendon to correct the deformity.

images Equipment

images Fluoroscopy unit to confirm reduction and hardware placement

images Preferred screw (and plating or staple) system

images Bone graft is not required but may be useful to fill any voids or gaps with deformity correction.

Positioning

images With a traditional triple arthrodesis, the patient is placed on the operating table in a modified lateral decubitus position (“sloppy lateral position”; FIG 2). This allows access to the lateral and medial hindfoot.

images The patient's torso is supported with a beanbag.

images An axillary roll is usually indicated.

images The contralateral hip is flexed slightly to make room for a stack of folded sheets on which the operative leg is placed.

images The opposite leg must be padded if it contacts the beanbag.

images I routinely use a thigh tourniquet if I am considering an Achilles tendon lengthening.

images If an Achilles tendon lengthening is unnecessary, a calf tourniquet is adequate.

Approach

images The traditional utilitarian lateral approach uses a 7to 8-cm incision from the tip of the fibula toward the base of the fourth metatarsal.

images The traditional utilitarian dorsomedial approach uses a 7to 8-cm incision from the anterior aspect of the anterior medial malleolus toward the dorsomedial base of the first metatarsal.

images If equinus contracture is present, I first perform an Achilles tendon lengthening.

images

FIG 2 • The patient is placed on a beanbag in a modified lateral position that allows access to the medial and lateral foot. A stack of folded sheets is placed under foot to be operated.

TECHNIQUES

LATERAL EXPOSURE

images Create a lateral longitudinal incision (TECH FIG 1A).

images Protect the sural nerve (TECH FIG 1B).

images Create the interval between the peroneal tendons and the extensor digitorum brevis (EDB) muscle.

images Elevate the EDB muscle with its fascia dorsally (TECH FIG 1C).

images Avoid “shredding” the muscle and fascia, as it will be used as the deep layer closure at the completion of the surgery.

images Release the bifurcate (calcaneonavicular and calcaneocuboid) ligament that lies deep to the EDB muscle.

images Release the calcaneocuboid capsule also (TECH FIG 1D).

images

TECH FIG 1 • A. Standard lateral approach. B. Protect the sural nerve. C. Elevate the EDB muscle and fascia. D. Expose the subtalar joint. A blunt retractor may be placed deep to the calcaneofibular ligament. E. Identify the calcaneocuboid joint. In this patient with an inflammatory arthropathy, the joint is distorted. F,G. Subtalar joint exposed with a distraction device.

images Place a blunt retractor between the lateral subtalar joint and the calcaneofibular ligament (TECH FIG 1E).

images The lateral talonavicular joint may also be accessed through this approach.

images Use a distractor to expose the subtalar joint first (TECH FIG 1F,G) and then the calcaneocuboid joint.

SUBTALAR, CALCANEOCUBOID, AND LATERAL TALONAVICULAR JOINT PREPARATION

images The preparation is the same for all three joints.

images Remove residual articular cartilage with an sharp elevator or chisel (TECH FIG 2A).

images Preserve the native subchondral bone architecture.

images Drill or chisel (“feather”) the subchondral bone to allow for vascular channels to form at the arthrodesis surfaces while maintaining subchondral bone architecture (TECH FIG 2B,C).

images For the subtalar joint, include not only the posterior facet but also the middle and anterior facets.

images However, be careful to not disrupt the delicate vasculature on the undersurface of the talar neck, if possible.

images The calcaneocuboid joint is a “saddle” joint, so avoid simply driving a chisel directly across the joint surfaces as it may result in more than desired bone removal, particularly when correcting pes planovalgus (TECH FIG 2D,E).

images The lateral talonavicular joint is often difficult to reach from the medial approach, but the lateral exposure affords satisfactory access to prepare this aspect of the talonavicular joint (TECH FIG 2F,G).

images I irrigate the joint before drilling the subchondral bone. Drilling creates reamings that serve as bone graft, and I do not want to wash the reamings away.

images

images

TECH FIG 2 • A. Chisel being used to remove residual cartilage. B,C. Preparing the subtalar joint. B. Drill being introduced. C. The reamings created will serve as bone graft. D,E. Preparing the calcaneocuboid joint. D.Chisel being used to remove residual cartilage. E. Drilling the subchondral bone to promote fusion and adding reamings that serve as bone graft. F,G. Exposure of the lateral talonavicular joint.

MEDIAL EXPOSURE

images Create a longitudinal incision (TECH FIG 3A).

images Cauterize connecting branches of the saphenous vein so the vein can be mobilized.

images Identify the tibialis anterior tendon and protect it throughout the procedure (TECH FIG 3B).

images Typically fibers of the extensor retinaculum must be released to access the tibialis anterior tendon.

images Perform a longitudinal capsulotomy (TECH FIG 3C,D).

images The spring ligament may need to be divided and the PTT tendon may need to be released from the navicular to improve access to the talonavicular joint.

images

TECH FIG 3 • A,B. Medial approach to the talonavicular joint. C. Medial exposure after capsulotomy. D. Close-up demonstrating erosive changes in the talonavicular joint in a patient with an inflammatory arthropathy.

TALONAVICULAR JOINT PREPARATION

images Use a distractor to gain full exposure to the talonavicular joint (TECH FIG 4A,B).

images In brittle bone, be careful when applying pressure to the navicular as it may fracture.

images Remove the residual articular cartilage from the talonavicular joint (TECH FIG 4C).

images In pes planovalgus deformity, the talar head may be weak, so be careful not to gouge the talar head when attempting to delaminate the residual articular cartilage.

images The lateral talar head should have already been prepared from the lateral approach.

images Remove cartilage from the navicular.

images Penetrate the subchondral bone to promote fusion.

images The talus is relatively easy to access with a smalldiameter drill bit (TECH FIG 4D). Be careful using a chisel on the talar head as it may fracture.

images The navicular can also be readily drilled.

images I do not often use a burr to prepare subchondral bone for fusion, but on the navicular it is sometimes very effective, provided cold water or saline irrigation is used simultaneously to limit bone necrosis. However, this may wash away desirable reamings that could serve as bone graft.

images As for the preparation of the other joint surfaces, I irrigate the talonavicular joint before drilling then try to maintain the reamings so they can be used as bone graft.

images

TECH FIG 4 • A. Talonavicular joint distracted. B. Dèbriding the joint with a rongeur. C. A chisel is used to remove residual articular cartilage. D. Drilling the subchondral bone to promote fusion.

HINDFOOT REDUCTION

images Place bone graft in the arthrodesis sites at this time, before the reduction is performed.

images I routinely use bone graft to fill voids at the surfaces to be fused. While this is not mandatory, I believe that filling the voids enhances the body's ability to form bridging trabeculations.

images The calcaneus must be centered properly under the talus.

images Through the lateral wound, the optimal relationship of the posterior facet can be assessed and controlled. (TECH FIG 5A,B).

images Physiologically there is a gap between the anterolateral talus and the anterior calcaneal process, and this should be re-created.

images In correcting severe pes planovalgus, I aim to overcorrect the calcaneus beneath the talus (TECH FIG 5C).

images Once the optimal subtalar relationship established, I provisionally pin the subtalar joint.

images I use a guide pin for the intended cannulated screw and try to place the pin in the intended trajectory for the screw (TECH FIG 5D,E).

images Typically I have an assistant working with me, so I hold the reduction while the assistant places the guide pin from the calcaneal tuberosity into the talar body.

images The dual-incision approach affords the surgeon the ability to palpate the talonavicular and calcaneocuboid joint reductions simultaneously.

images With the subtalar joint reduced, I then attempt to reduce the talonavicular joint to an anatomic position. I can palpate both sides of the talonavicular joint by having two incisions (TECH FIG 5F).

images When correcting pes planovalgus deformity, I err on the side of overcorrection of the navicular on the talar head.

images Once I have the talonavicular joint reduced, I protect the tibialis anterior tendon and have my assistant drive two guide pins, appropriately spaced from one another, from the navicular into the talar head (TECH FIG 5G).

images I attempt to place the screw from the most distal aspect of the navicular, even reaming the medial wall of the first cuneiform slightly, so the pin needs to be flush against the medial aspect of the first cuneiform.

images Finally, I provisionally pin the calcaneocuboid joint.

images To create a relief area on the anterior process of the calcaneus for the screw insertion, I remove a small wedge of bone from the anterior process using a rongeur.

images I routinely push up on the cuboid and down on the anterior process of the calcaneus to reduce the joint.

images Despite the lateral approach, optimal longitudinal orientation of the guide pin across the calcaneocuboid joint is not possible.

images I sometimes create a stab incision behind the peroneal tendons, dissect carefully deep to the sural nerve and tendons, creating a soft-tissue tunnel, insert a drill sleeve, and then deliver the guide pin safely to the anterior process of the talus.

images The guide pin is driven across the joint.

images

TECH FIG 5 • Reducing the hindfoot. A,B. Checking the subtalar joint reduction. C. The hindfoot is maintained in the corrected position. Lateral (D) and mortise (E) fluoroscopic views after a guide pin was placed across the reduced subtalar joint. F. Reduction of talonavicular joint. G. Guide pins placed across talonavicular joint.

HINDFOOT STABILIZATION

images The reduction and the position of the guide pins are checked fluoroscopically (TECH FIG 6A).

images Adjustments are made as necessary.

images At this stage, I also routinely check the ankle fluoroscopically to be sure there is no ankle deformity that may distort the true hindfoot alignment.

images I determine proper screws lengths and overdrill the guide pins, but only to the initial aspect of the second bone.

images Most modern screws are self-drilling and self-tapping; however, particularly in the navicular, I prefer to predrill to diminish the risk of navicular fracture.

images By not drilling the full length of the planned screw, purchase of the screw is typically improved.

images I first place the subtalar screw, as a compression screw (TECH FIG 6B,C).

images Next, I place the two talonavicular screws (TECH FIG 6DF).

images The first screw is a compression screw.

images I use a positional screw for the second screw.

images If greater talonavicular stability is needed, I create a small dorsal incision over the midfoot; protect the superficial peroneal nerve, extensor tendons, and the deep neurovascular bundle; and using a drill sleeve, place a guide pin from the centrolateral navicular into the talar body or sometimes through the inferior talar body and into the calcaneus. Over this I place a third talonavicular screw, either positional or compression, although with two screws medially further compression is generally not possible.

images For the calcaneocuboid joint, I protect the soft tissues and overdrill only the anterior calcaneal process. Then I insert a compression or positional screw across the calcaneocuboid joint (TECH FIG 6G,H).

images If the joint is well reduced, I tend to use a positional screw; if the joint could stand to be compressed for better bony apposition, however, I place a compression screw.

images As mentioned earlier, I push up on the cuboid and down on the anterior calcaneal process to maintain the reduction and to make sure the cuboid does not sag, occasionally leaving it prominent postoperatively. However, with an anatomic reduction, this is rarely an issue.

images Occasionally, I add a lateral compression plate or staple across the calcaneocuboid joint to augment the fixation.

images I get final fluoroscopic confirmation of alignment, bony apposition at the arthrodesis sites, and hardware position (TECH FIG 6I,J).

images

images

TECH FIG 6 • A. Fluoroscopic confirmation of the guide pins placed across the talonavicular joint (this patient had undergone prior midfoot arthrodesis). B,C. Clinical and fluoroscopic views of the subtalar screw in place. D–F. Clinical and fluoroscopic views of the talonavicular screws in place. One partially threaded compression screw is placed first, and one fully threaded positional screw is placed second. G,H. Calcaneocuboid screw. A separate stab incision is made with a carefully prepared soft tissue tunnel under the sural nerve and peroneal tendons. Note thumb pressure pushing up on the cuboid to maintain joint reduction and a more favorable position of the cuboid. I,J. Final AP and lateral fluoroscopic views confirming appropriate reduction, bony apposition at the arthrodesis sites, and proper hardware position.

Closure

images I routinely pack bone graft at the “quadruple arthrodesis” site, where talus, calcaneus, navicular, and cuboid meet at the lateral aspect of the talonavicular joint (TECH FIG 7).

images Medially the capsule is reapproximated.

images Laterally the fascia overlying the EDB muscle can usually be reapproximated to soft tissues adjacent to the peroneal tendons.

images Any bone graft in the soft tissues is irrigated away, as it may interfere with wound healing.

images Next, the subcutaneous tissues are closed.

images The skin incisions are then reapproximated to tensionless closures.

images I routinely release the tourniquet prior to subcutaneous layer closure.

images I also routinely use a lateral drain.

images The stab incisions for screw placement are closed.

images Sterile dressings and a posterior or sugar-tong splint are placed over adequate padding, with the ankle in neutral position.

images

TECH FIG 7 • Bone grafting the confluence of all four hindfoot bones, at the “quadruple arthrodesis” site.

images

POSTOPERATIVE CARE

images I routinely keep patients overnight for pain control, nasal oxygen (which may improve wound healing), and limb elevation.

images While I recognize that some of my colleagues perform this surgery as a pure outpatient procedure, I believe that one night (which still qualifies as an outpatient procedure) is in the patient's best interest after major hindfoot surgery.

images The patient wears a splint for 2 weeks.

images The patient returns to the clinic at 2 weeks for suture removal and short leg cast.

images The patient returns to the clinic at 6 weeks after surgery for radiographs out of cast and repeat casting.

images Touch-down weight bearing is the rule for a full 10 weeks.

images The patient returns to the clinic at 10 weeks and if repeat simulated weight-bearing radiographs suggest healing and no complications, he or she can be placed in a cam boot with gradual progression to full weight bearing by 12 to 14 weeks.

images The patient returns to the clinic at 14 to 16 weeks for full weight bearing radiographs (FIG 3), then gradual progression to full activities.

OUTCOMES

images Patients are generally improved with an appropriately performed triple arthrodesis.

images At intermediate to long-term follow-up, patients are functional in their activities of daily living but few are able to perform demanding recreational activities.

images With time, patients tend to develop adjacent joint arthritis, but it is unclear if this causes functional deficits.

images “Triple arthrodesis” performed through a single medial incision and including only the subtalar and talonavicular joints is gradually displacing the traditional triple arthrodesis. Results of this procedure are promising, but it is not clear if they are more favorable than those of the traditional triple arthrodesis.

COMPLICATIONS

images Nonunion

images Malunion

images Wound dehiscence

images Infection

images Sural neuralgia

images Prominent hardware

images Persistent pain despite appropriate management and satisfactory clincal and radiographic findings

images

FIG 3 • Follow-up weight-bearing radiographs of the patient with fixed hindfoot deformity secondary to posterior tibial tendon dysfunction and spring ligament tear. Note the congruent alignment of the talar–first metatarsal axis in both the AP and lateral views.

REFERENCES

· Bednarz PA, Monroe MT, Manoli A II. Triple arthrodesis in adults using rigid internal fixation: an assessment of outcome. Foot Ankle Int 1999;20:356–363.

· Haritidis JH, Kirkos JM, Provellegios SM, Zachos AD. Long-term results of triple arthrodesis: 42 cases followed for 25 years. Foot Ankle Int 1994;15:548–551.

· Knupp M, Skoog A, Törnkvist H, Ponzer S. Triple arthrodesis in rheumatoid arthritis. Foot Ankle Int 2008;29:293–297.

· Pell RF IV, Myerson MS, Schon LC. Clinical outcome after primary triple arthrodesis. J Bone Joint Surg Am 2000;82A:47–57.

· Rosenfeld PF, Budgen SA, Saxby TS. Triple arthrodesis: is bone grafting necessary? The results in 100 consecutive cases. J Bone Joint Surg Br 2005;87B:175–178.

· Sangeorzan BJ, Smith D, Veith R, Hansen ST Jr. Triple arthrodesis using internal fixation in treatment of adult foot disorders. Clin Orthop Relat Res 1993;294:299–307.

· Saltzman CL, Fehrle MJ, Cooper RR, et al. Triple arthrodesis: twentyfive and forty-four-year average follow-up of the same patients. J Bone Joint Surg Am 1999;81:1391–1402.

· Smith RW, Shen W, Dewitt S, Reischl SF. Triple arthrodesis in adults with non-paralytic disease: a minimum ten-year follow-up study. J Bone Joint Surg Am 2004;86A:2707–2713.

· Song SJ, Lee S, O'Malley MJ, et al. Deltoid ligament strain after correction of acquired flatfoot deformity by triple arthrodesis. Foot Ankle Int 2000;21:573–577.



If you find an error or have any questions, please email us at admin@doctorlib.org. Thank you!