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CHAPTER

20

Arthrodesis of the Foot


and Ankle
Roger A. Mann

TECHNICAL CONSIDERATIONS
SOFT TISSUE CONSIDERATIONS
SURGICAL PRINCIPLES

Arthrodesis plays an important role in reconstructive


surgery of the foot and ankle, enabling the surgeon to
create a painless, stable, plantigrade foot. It is used
most often to correct a painful joint secondary to
arthrosis, chronic instability of the foot and ankle from
muscle dysfunction (e.g., posterior tibial tendon,
poliomyelitis), or a deformity that has resulted in a
nonplantigrade foot.
Arthrodesis can greatly enhance a patients functional capacity, but it places increased stress on the
joints proximal and distal to the fusion site. After an
ankle or triple arthrodesis, approximately 30% of
patients demonstrate arthroses distal or proximal to
the fusion site within 5 years. Although most of these
findings are radiographic, their presence at 5 years
does not bode well for what will occur at these joints
20 to 30 years in the future.
Many factors probably affect the onset of this arthrosis besides the increased stress. One factor is probably
related to the overall stiffness or laxity of the surrounding joints. The stiffer the surrounding joints, the
less the patient is able to dissipate the increased stress
created by the fusion compared with a patient who has
more joint laxity. Because an arthrodesis is often per-

COMPLICATIONS
SPECIFIC ARTHRODESES (video clips
11-14)

formed on a traumatized extremity, the adjacent joints,


although not demonstrating arthrosis, might have sustained tissue damage at the time of the initial injury
that makes them more vulnerable to develop arthrosis
when subjected to increased stress.
Although this chapter discusses arthrodesis of the
joints of the foot and ankle, the clinician should
always remember that, if possible, arthrodesis should
be avoided, particularly in patients younger than 50
years. Often an osteotomy or a tendon transfer can be
used to create a plantigrade foot without resorting to
an arthrodesis. It is often more challenging to the
surgeons creativity to avoid an arthrodesis. If the
surgeon can offer the patient 5 to 10 years of improved
quality of life from a reconstructive procedure without
using an arthrodesis, this is the desired approach.

TECHNICAL CONSIDERATIONS
The two basic types of arthrodeses are an in situ fusion
and one that corrects a deformity. In an in situ fusion,
positioning the foot or ankle is usually not difficult because no deformity is present. In a deformity1087

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correcting fusion, however, the surgeon must decide the


precise alignment that must be obtained to produce a
plantigrade foot. To determine the alignment, the
surgeon first must evaluate the normal extremity.
With the patient in a supine position, the patella is
aligned to the ceiling, giving the surgeon a reference
point from which all measurements are made. The
degree of internal or external rotation, varus or valgus,
and abduction or adduction is carefully noted. A
particular arthrodesis is not always placed into a standard alignment; rather, it must be individualized for
each patient. Using the patella as a reference point
makes alignment at surgery much easier and more
precise.
When evaluating the patient for an arthrodesis, the
surgeon must also carefully examine the adjacent
joints for range of motion and overall alignment.
Because an arthrodesis places more stress on the surrounding joints, if one of these joints has mild arthrosis, the prognosis for success is diminished. As an
example, when a double or triple arthrodesis needs to
be performed and there is mild arthrosis of the ankle
or valgus or varus tilt of the talus in the ankle mortise,
following a double or triple arthrodesis the ankle joint
can deteriorate more rapidly or become more symptomatic as a result of the increased stress. Therefore it
is important to inform the patient who is about to
undergo a triple or double arthrodesis in the presence
of early arthrosis of the ankle joint that although the
fusion will create a painless hindfoot, it might also
result in rapid deterioration of the ankle. Similarly, if
the patient has concomitant arthrosis of the tarsometatarsal joints that is not symptomatic, it can
become symptomatic after a triple or double arthrodesis because of the added stress from the proximal
fusion. In some cases when multiple joints are
involved, it may be more desirable to treat the patient
conservatively with an orthotic device such as an
anklefoot orthosis (AFO) rather than carry out an
arthrodesis.
Once a decision has been made to perform an
arthrodesis, the next most critical factor is to establish
the proper alignment of the fusion site. To do this, the
surgeon must consider the entire lower extremity and
not just the foot. The position of the knee or the bow
of the tibia, which can occur either naturally or as a
result of prior trauma, must be carefully examined
when planning the arthrodesis. The alignment of the
extremity distal to the fusion site is also important to
be sure a plantigrade foot is created.
The biomechanics of the foot dictates its optimal
alignment. When the subtalar joint is placed into an
everted (valgus) position, it creates flexibility of the transverse tarsal joint and results in a supple forefoot. When
the subtalar joint is in an inverted (varus) position, it

locks the transverse tarsal joint. This creates a rigid


forefoot and increased stress under the lateral aspect
of the foot. It is therefore important to align the subtalar joint in 5 to 7 degrees of valgus when a fusion is
carried out in order to maintain flexibility of the forefoot. When a talonavicular arthrodesis is performed,
the surgeon must remember that motion in the subtalar joint will no longer occur. Therefore the subtalar
joint must be aligned into 5 degrees of valgus, after
which the talonavicular joint is aligned while taking
into account abduction or adduction of the transverse
tarsal joint as well as correcting any forefoot varus that
might be present. This complex alignment creates a
technically challenging situation for the surgeon. If
the joints surrounding the talonavicular joint are
not properly aligned, a plantigrade foot will not be
created.
When arthrodesing the tarsometatarsal joints, the
surgeon should always try to match the abnormal foot
to the normal foot by carefully evaluating the weightbearing posture of both feet preoperatively. The most
common deformity is abduction and varying degrees
of dorsiflexion. Any malalignment needs to be corrected. Once the first metatarsocuneiform joint is stabilized, the other joints need to be aligned, both in the
transverse and in the dorsoplantar direction. This will
align the metatarsal heads and prevent one from being
too prominent, which can result in an intractable
plantar keratosis.

SOFT TISSUE CONSIDERATIONS


The soft tissue envelope of the foot and ankle often
contains little or no fatty tissue. At times this lack of
soft tissue padding has been further compromised by
previous surgery or trauma to the soft tissues, resulting in adherence of the soft tissue to the underlying
bone. The surgical approach should be as precise as
possible to avoid placing undue tension on the skin
edges. If significant realignment is to be achieved, it
must not be at the expense of proper wound approximation. This occasionally occurs when attempting to
correct a valgus deformity of the heel in which an
opening lateral wedge osteotomy results in increased
tension on the lateral skin edges, which makes closure
difficult. Skin flaps should be made as full thickness as
possible to diminish the possibility of a skin slough.
Creating an incision down to the bone, then retracting
on the deep structures and not the skin edge, is probably the best way to avoid a skin problem.
When making an incision, the surgeon must always
be cognizant of the location of the cutaneous nerves
about the foot and ankle. Although cutaneous nerves
tend to lie in certain anatomic areas, great variation

CHAPTER 20

exists. Therefore, as the incision is carried down


through the subcutaneous tissues, it is important to
always look for an aberrant cutaneous nerve. The cutaneous nerves can be quite superficial and easily transected but sometimes become adherent within scar
tissue. If this occurs, a painful scar or dysesthesias
distal to the injury can result in a dissatisfied patient
despite a satisfactory fusion.
Another unique problem after foot surgery is the
impact of footwear, which can rub against a subcutaneous neuroma, further aggravating the problem.
If a nerve is inadvertently transected during a
surgical approach, it should be carefully dissected
to a more proximal level and the cut end buried
beneath some fatty tissue or muscle so that it will not
become symptomatic. Sometimes, although a nerve is
not cut, it can be stretched as a result of retraction,
which can result in a transient loss of function.
Patients must be made aware of the potential for
nerve injury and the area where they can experience
numbness.

SURGICAL PRINCIPLES
When carrying out an arthrodesis of the foot and
ankle, the following surgical principles should be carefully observed:
A well-planned incision of adequate length to
avoid undue tension on the skin edges.
An attempt should be made to create broad, congruent cancellous surfaces that can be placed into
apposition to permit an arthrodesis to occur.
The arthrodesis site should be stabilized with
rigid internal fixation. This sometimes depends
on the surgeons ingenuity in creating a rigid
construct, particularly if poor bone stock is
present.
When performing a fusion, the hindfoot must be
aligned to the lower extremity and the forefoot to
the hindfoot to create a plantigrade foot.
After exposure of the fusion site, the soft tissues surrounding the joints are removed. This mobilizes the
joints, allowing the surgeon to realign the foot. At
times, because of previous trauma or severe malalignment, mobilization of the joints is not possible and
bone resection needs to be carried out. In my experience, however, the majority of cases can be aligned,
even when a significant deformity is present, by complete mobilization of the involved joints followed by
manipulation to create a plantigrade foot.
Once the joints have been mobilized and it is determined that bone does not need to be removed, the
articular surfaces are meticulously debrided of their

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articular cartilage and any fibrous tissue to subchondral bone. This is achieved with a curet or a small,
sharp osteotome. A lamina spreader or a towel clip can
facilitate distraction of the articular surfaces, making
the debridement easier, but this can damage the bone
if it is soft.
Once the subchondral bone is exposed, the foot is
once again manipulated, placing it into the desired
alignment. If this is achievable, internal fixation can be
inserted. If large amounts of bone need to be removed
to create a plantigrade foot, this should be done before
removing the articular cartilage. The subchondral surfaces are heavily feathered or scaled with a 4- or 6-mm
osteotome, which creates a broader, bleeding cancellous surface required for successful fusion. The articular surfaces to be arthrodesed are brought together and
stabilized with provisional fixation. Then interfragmentary compression is achieved using appropriate
definitive fixation.
By carrying out a fusion in this manner, broad bleeding surfaces of cancellous bone are brought together,
which provides the best possible chance for a successful arthrodesis. In my experience, bone graft from the
iliac crest is rarely necessary when carrying out an
arthrodesis. Sometimes bone has been lost, making a
bone graft necessary, but in an in situ fusion, grafting
is not usually required. If a small amount of bone is
needed, it can be harvested from the calcaneus, medial
malleolus, or proximal medial tibia without violating
the iliac crest and causing its attendant morbidity.
Likewise, bone substitutes or other materials are rarely
required if the bone preparation is carried out correctly.
For internal fixation, I prefer an interfragmentary
screw that compresses the joint surfaces. At times a
power staple, a plain staple, or a plate may be used.
Although an external fixator can provide excellent fixation, if possible a closed system without an external
fixator is safer due to possible pin tract problems with
prolonged immobilization. Because of soft bone or
soft tissue problems, however, it may become necessary to use an external fixator. Under these circumstances this device provides excellent rigid fixation.
The skin closure after a fusion is very critical. The
surgeon should always attempt, if possible, to obtain
a soft tissue cover underneath the skin flaps, such as
fat or muscle. This is important because if a superficial
wound slough occurs, it will be over an underlying bed
of soft tissue rather than bone. This is not always possible, particularly on the dorsum of the foot, where
bone lies directly beneath the skin. If any tension is
noticeable on the skin edge, some type of a relaxing
skin suture should be used. A drain is always useful if
profuse bleeding is anticipated.
The initial postoperative dressing is very important
and should support the soft tissues as well as the

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arthrodesis site. A heavy cotton gauze roll provides


uniform compression about the extremity, supported
by plaster splints. A circumferential cast should be
avoided during the immediate postoperative period
because it can result in undue pressure against the
expanding extremity, increasing pain and possibly
jeopardizing healing of the wound edges. The postoperative dressing is used for approximately 10 to 14 days
before removing the sutures.
After most fusions, bupivacaine hydrochloride
(bupivacaine) is instilled into the wounds to diminish
the initial postoperative pain. A popliteal block is
used, which generally provides 18 to 36 hours of pain
relief. The popliteal block may be repeated after 18 to
24 hours if the patient has too much breakthrough
pain. It is much easier to prevent postoperative
pain than play catch-up after the pain cycle has been
established.

COMPLICATIONS
The main complications after an attempted arthrodesis include infection, skin slough, nerve disruption or
entrapment, nonunion, and malalignment.
The possibility of infection is always a postsurgical
concern. During surgery, antibiotic irrigation as well as
parenteral antibiotics can help minimize this complication. Good surgical technique with careful handling
of the tissues, removal of devitalized tissue, and prevention of hematoma formation also play an important role in minimizing the possibility of infection. If
an infection occurs, it is important to recognize and
treat it promptly with appropriate antibiotics.
A skin slough around the foot and ankle can present
a difficult management problem because of the lack of
adequate subcutaneous tissue. The potential for a skin
slough can be minimized by creating full-thickness
skin flaps, making incisions of adequate length to minimize tension on the skin edges, using postoperative
drainage when appropriate, and applying a firm compression dressing postoperatively. Placing a patient
into a cast without adequate padding is not advisable.
When a skin slough occurs, it is important to treat it
vigorously with local debridement and application of
wet-to-dry dressings to promote granulation tissue,
followed by coverage with a split-thickness skin graft.
Vacuum-assisted closure (wound-VAC) can be extremely
useful to manage a wound slough. If the slough is too
large, a plastic surgeon should be consulted.
Nerve disruption or entrapment around the foot and
ankle not only creates numbness but also can cause
chronic pain from footwear rubbing against the
neuroma. A carefully planned surgical approach is the
best treatment, but if a symptomatic neuroma occurs,

it should be identified and resected into an area not


subject to pressure and then buried either beneath
muscle or into bone.
A nonunion of an attempted fusion site is always an
unfortunate event. As a general rule, of the joints
around the foot and ankle, the talonavicular probably
has the highest incidence of nonunion. Its curved surfaces make adequate exposure difficult, and preparation of the joint surfaces may be inadequate. Even
when the bone surfaces have been adequately
prepared, nonunion can occur if internal fixation is
inadequate.
The vascularity of the bone plays an important role
in the development of a nonunion. Avascular necrosis
of the talus from any cause creates a situation that is
very difficult to manage. When avascular bone is
present, it is often not possible to obtain a fusion to
the dysvascular bone, and an attempt must be made
either to bypass the avascular area or to determine the
portions of the talus that still have adequate vascularity and attempt a fusion using these areas. The navicular can develop evidence of avascular changes either
spontaneously or secondary to previous injury. When
this problem is encountered, the involved area needs
to be resected and bone grafted. When dealing with
dysvascular bone preoperatively, it is important to
identify the areas of potential problems and create a
surgical plan that will help solve the problem. Recognizing a dysvascular problem also helps to predict the
outcome for the patient.
Occasionally an asymptomatic nonunion occurs
and can be treated with observation. After a triple
arthrodesis the talonavicular joint occasionally does
not fuse, but because of a successful fusion of the subtalar and calcaneocuboid joints, it may not be a source
of pain. If a nonunion is symptomatic, a revision of
the fusion site needs to be considered. If the overall
alignment of the nonunion is satisfactory, bone grafting by inlaying bone across the nonunion site often
results in a fusion if internal fixation is adequate. At
other times, if the nonunion site has resulted in loss
of alignment, the area needs to be revised. This is done
by removing the internal fixation and the fibrous tissue
between the bone ends, realigning the surfaces, performing a bone graft if necessary, and inserting rigid
fixation.
Malalignment after a fusion is a problem that usually
can be avoided by meticulous bone preparation and
rigid internal fixation. Malalignment after a triple
arthrodesis is seen most often. The usual malalignment following a triple arthrodesis is varus of the heel
and adduction or supination (or both) of the forefoot.
This requires the patient to walk on the lateral aspect
of the foot, causing patient dissatisfaction. When a
fusion of the hindfoot is performed, it is important to

CHAPTER 20

evaluate the entire lower extremity preoperatively and


intraoperatively to reduce the risk of malalignment.
After carefully observing the normal extremity, the
surgeon should always relate the foot alignment to the
patella. Once the joint surfaces have been prepared
and provisionally stabilized, the alignment should
again be checked to be sure it is correct. Malalignment
can only be prevented by careful observation of the
extremity at surgery.

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It was previously believed that an isolated


subtalar arthrodesis should not be carried out,
and that a triple arthrodesis would be the procedure of choice when a hindfoot fusion was
indicated. The literature has demonstrated,
however, that an isolated subtalar arthrodesis
produces a superior result with less stress on the
ankle joint than a triple arthrodesis.*
Indications

SPECIFIC ARTHRODESES
Much has been written about arthrodesis of the foot
and ankle. Many surgical approaches, site preparations, and types of internal and external fixation have
been proposed. This section presents the techniques I
have evolved over time and that result in a satisfactory
outcome with careful adherence to technique. Other
techniques may be equally effective, but reproducibly
good results have been achieved with subtalar
arthrodesis, talonavicular arthrodesis, double arthrodesis, triple arthrodesis, naviculocuneiform arthrodesis, and tarsometatarsal arthrodesis.

SUBTALAR ARTHRODESIS
An isolated subtalar joint arthrodesis results in
satisfactory correction of deformity and relief of
pain that enables the patient to regain the
ability to perform most activities. Of the hindfoot fusions, the patients ability to achieve a
high level of function is greatest after a subtalar
arthrodesis. Biomechanically, the position of the
subtalar joint determines the flexibility of the
transverse tarsal (talonavicularcalcaneocuboid)
joint, and therefore it is imperative that a subtalar arthrodesis be positioned in about 5
degrees of valgus to permit mobility of the
transverse tarsal joint. If it is placed in varus, the
transverse tarsal joint is locked, and the patient
tends to walk on the lateral side of the foot. The
posture of the forefoot also needs to be considered because if there is more than 10 to 12
degrees of fixed forefoot varus, after a subtalar
arthrodesis the patient cannot compensate for
this deformity and walks on the lateral side of
the foot, resulting in discomfort beneath the
fifth metatarsal head or base, or both, and in
severe stress on the lateral ankle ligaments.
Occasionally the fixed forefoot varus can be corrected by carrying out a simultaneous naviculocuneiform fusion.

The most common indication for a subtalar


arthrodesis is arthrosis secondary to trauma,
usually a calcaneal fracture, rheumatoid arthritis,
primary arthrosis, or talocalcaneal coalition that
cannot be resected. It is also indicated for a
muscle imbalance (e.g., loss of peroneal muscle
function) or posterior tibial tendon dysfunction
with an unstable subtalar joint but normal transverse tarsal joint motion and a fixed forefoot
varus deformity of less than 12 degrees. A subtalar arthrodesis is indicated in patients with a
neuromuscular disorder such as CharcotMarie
Tooth disease, poliomyelitis, or nerve injury with
instability of the subtalar joint.
Although a subtalar fusion can have an excellent result, if the deformity can be corrected with
a calcaneal osteotomy instead of a fusion, this
should be strongly considered.
Position of Arthrodesis
The subtalar arthrodesis should be placed in
approximately 5 degrees of valgus. Varus should
be avoided because it results in increased stability of the transverse tarsal joint. Conversely,
too much valgus results in an impingement
against the fibula and increased stress along the
medial aspect of the ankle joint.
Surgical Technique
1. The patient is placed in a supine position
with a support under the ipsilateral hip to
facilitate exposure of the subtalar joint
(video clip 11).
2. A thigh tourniquet is applied.
3. The skin incision begins at the tip of the
fibula and is carried distally toward the base
of the fourth metatarsal. When an isolated
subtalar arthrodesis is carried out, the incision usually stops at about the level of the
calcaneocuboid joint (Fig. 201A).
*References 1-4, 7, 8, 10, 11, and 14-16.

Base fourth
metatarsal

Fibula

Incision

Calcaneocuboid joint

A1
A2

D1

D2

Figure 201 Subtalar joint fusion. A, Site of fusion. Incision is made from the tip of the fibula and extends toward the base of
the fourth metatarsal so as to place it in the interval between a branch of the superficial peroneal nerve dorsally and the sural
nerve plantarly. B, Exposure of subtalar joint with Weitlaner retractor. C, A lamina spreader placed within the sinus tarsi area
exposes the posterior and middle facets. D, When a screw is used for fixation of the subtalar joint, it is placed through the posterior facet into the neck of the talus. Circle in the posterior facet (PF) demonstrates where the tine of the guide is placed in
order to accurately place the screw. MF identifies the middle facet. The anterior cruciate guide is placed into the subtalar joint
with the tine in posterior facet, as marked on the model. The guide is then set on the heel, after which a guide pin is placed
across the subtalar joint. E, Preoperative and postoperative radiographs demonstrate subtalar fusion using a 7.0-mm screw. The
screw begins off the weight-bearing area of the heel. F, Preoperative and postoperative radiographs demonstrate subtalar
arthrodesis after calcaneal fracture. Interpositional bone graft is used to reestablish the talocalcaneal relationship. Interpositional
bone graft is rarely required to obtain a satisfactory result. G, When lateral subluxation of the subtalar joint is present, the joint
must be reduced and not fused in situ. The lateral aspect of the calcaneus should line up with the lateral aspect of the talus. H,
Example of in situ fusion with persistent lateral subluxation of the subtalar joint, resulting in subfibular impingement and persistent pain. I, Preoperative and postoperative radiographs demonstrating subtalar fusion in a patient with prior ankle fusion who
developed arthrosis of the subtalar joint.

1092

E1

E2

F1

F2

I1

I2

Figure 201contd
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4. While deepening the incision, the surgeon


should be cautious, because the anterior
branch of the sural nerve may be crossing
the operative site.
5. The incision passes along the dorsal aspect
of the peroneal tendon sheath and distally
along the floor of the sinus tarsi.
6. The extensor digitorum brevis muscle origin
is detached and the muscle belly reflected
distally, exposing the underlying sinus tarsi,
subtalar joint, and calcaneocuboid joint
(Fig. 201B). The fat pad is dissected out of
the sinus tarsi and reflected dorsally.
7. A small elevator is passed along the lateral
side of the posterior facet of the subtalar joint. It is not necessary to strip the peroneal tendons off the lateral side of the
calcaneus unless a lateral impingement
from a previous calcaneal fracture requires
decompressing.
8. With a curet, the contents of the sinus tarsi
and tarsal canal are removed.
9. A lamina spreader is inserted into the sinus
tarsi to visualize the posterior facet of the
subtalar joint (Fig. 201C). When looking
across the sinus tarsi, the surgeon can see
the middle facet of the subtalar joint. If the
surgery is being carried out for severe
arthrosis or a talocalcaneal coalition, it is
often not possible to open the subtalar joint
very far. Under these circumstances, a small
curet is used to remove the cartilage from
the posterior facet. A thin wide elevator
then can be inserted into the joint to pry it
open, after which a lamina spreader is
inserted.
10. With a curet of appropriate size, all the
articular cartilage is removed from the
posterior and middle facets. Using a curet,
a fairly safe instrument, reduces the possibility of damaging the flexor hallucis
longus tendon in the posterior aspect of
the joint or the neurovascular bundle along
the posteromedial aspect of the joint.
When removing the articular cartilage from
the middle facet, it is important not to
inadvertently go too far distally and damage
the cartilage on the plantar aspect of the
head of the talus, which lies just in front of
it.
11. Once all the articular cartilage has been
removed, the lamina spreader is removed
and the alignment of the subtalar joint

observed. If no deformity is present, the


surgeon may proceed with feathering or
scaling the articular surfaces. If a varus
deformity needs to be corrected, bone is
removed from the lateral aspect of the posterior facet to correct the deformity. It is
unusual to remove more than 3 to 5 mm of
bone when correcting a deformity, although
occasionally more bone needs to be
removed.
12. If a previous calcaneal fracture is present in
which the lateral wall needs to be decompressed, the peroneal tendons are elevated
from the lateral aspect of the calcaneus as
far posteriorly and plantarward as possible.
The impinging lateral wall is removed so
that it is approximately in line with the
lateral aspect of the talus. Sometimes, up to
7 to 10 mm of bone needs to be resected
in severe cases.
13. The posterior and middle facets, along with
the bone in the base of the sinus tarsi, are
heavily scaled. The dense bone in the floor
of the sinus tarsi is deeply scaled and is
mobilized so that it can be packed into the
tarsal canal after the internal fixation has
been inserted. The bone along the lateral
aspect of the calcaneus that forms the
anterior process may be mobilized to within
about 0.5 cm of the calcaneocuboid joint
and used for bone graft. When a lateral
decompression has been carried out, even
more bone is available to the surgeon.
Rarely is bone harvested from the iliac
crest.
14. After the bone surfaces have been scaled,
the subtalar joint is manipulated and placed
into the desired position of 5 degrees of
valgus.
Internal Fixation
Internal fixation is carried out with a fully
threaded 7.0-mm cannulated screw to obtain
maximum interfragmentary compression. A
washer is always used.
Screw patterns used for fixation of the subtalar joint include placing the screw from the neck
of the talus into the calcaneus, placing a screw
from the calcaneus into the talus, and placing
two screws between the calcaneus and the talus.
In most cases a single fully threaded screw
inserted through a glide hole in the calcaneus,

CHAPTER 20

starting the screw off the weight-bearing


surface, results in a rigid internal fixation with
maximum purchase in the neck of the talus,
which facilitates interfragmentary compression
of the subtalar joint. A washer is always used
because the grip of the screw in the neck of the
talus is so strong it can suck the screw into the
calcaneus without the washer.
15. The preferred method for stabilization, particularly with a valgus deformity, is to place
the 7.0-mm cannulated screw from the heel
across the subtalar joint and into the neck
of the talus. Screw placement is carried out
by placing an AO (Arbeitsgemeinschaft fr
Osteosynthese) anterior cruciate guide with
the sharp tine in the anterior aspect of
the posterior facet of the subtalar joint
(Fig. 201D). The other end of the guide is
placed on the heel pad just above the
weight-bearing area. This alignment
permits the screw to pass through the anterior aspect of the posterior facet and into
the neck of the talus, but the screw does not
penetrate the sinus tarsi area. This placement provides maximum purchase in the
talar neck from the fully threaded 7.0-mm
screw. A guide pin is drilled into the calcaneus until it is visible in the posterior facet
of the subtalar joint. If placement is
satisfactory, the anterior cruciate guide is
removed; if not, another attempt is made to
place the guide pin correctly.
16. The subtalar joint is placed into 5 degrees
of valgus, and the guide pin is drilled into
the talus until it just penetrates the dorsal
aspect of the neck of the talus. The pin
placement is confirmed by fluoroscopy.
17. With the pin properly placed, a 2-cm transverse incision is made over the entrance of
the guide pin into the heel pad. This incision must be made wide enough to accommodate the screw and washer to prevent
compressing the skin and fat of the heel
pad. The incision is carried directly to bone,
and slight stripping is done on each side of
the pin to accommodate the washer. A
depth gauge is used to determine the
length of the screw.
18. The guide pin is advanced through the talar
neck, appears on the dorsal aspect of the
ankle, and is secured with a clamp. This is
important so that when the holes are drilled,

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the guide pin cannot come out, which can


result in loss of alignment. The initial hole is
drilled with a 4.5-mm bit, just penetrating
the neck of the talus. A 7.0-mm drill bit is
used to overdrill only the calcaneus, creating the glide hole. The hole in the talar neck
is tapped, and a fully threaded, 7.0-mm
cannulated screw of appropriate length
is inserted. By overdrilling the calcaneus,
intrafragmentary compression at the arthrodesis site is achieved. With a fully threaded
screw, the maximum number of threads are
placed in the neck of the talus, maximizing
the compression. In placing the screw, the
surgeon should not have more than 2 to
3 mm of screw exposed on the neck of the
talus. The position of the screw is verified
with fluoroscopy (Fig. 201E).
19. The guide pin is removed, and the small
bone fragments that have been mobilized
are packed into the tarsal canal and the
sinus tarsi area. It is not necessary to fill up
the sinus tarsi completely when carrying out
an isolated subtalar joint fusion. If more
bone is needed, it can be obtained from the
calcaneus or medial malleolus, using a
trephine.
Closure
20. The fat pad previously dissected from the
sinus tarsi and retracted dorsally is placed
back into the sinus tarsi area. The extensor
digitorum brevis muscle is closed over the
area, creating a cover for the arthrodesis
site.
21. The subcutaneous tissue and skin are closed
in a routine manner, and bupivacaine is
instilled into and around the arthrodesis
site.
22. The patient is placed into a compression
dressing incorporating two plaster splints.
Postoperative Care
In the recovery room a popliteal block is used
to control postoperative pain. The patients
dressing is changed approximately 10 days after
surgery, and the sutures are removed. The
patient is placed into a removable cast with an
elastic bandage to control swelling but is kept
nonweight bearing for 6 weeks. At 6 weeks, if
the radiographs demonstrate that early union is

1096

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Arthritis, Postural Disorders, and Tendon Disorders

occurring, the patient is permitted to bear


weight as tolerated in a removable cast. Approximately 12 weeks after surgery, radiographs are
obtained, and if satisfactory union has occurred,
the patient is permitted to ambulate with an
elastic stocking.
Complications
Nonunion of the subtalar joint occurs infrequently. The few nonunions that we have
encountered are usually in young patients after
a severe intraarticular calcaneal fracture in which
the bone in the midportion of the calcaneus
appears to be sclerotic and may be dysvascular.
A nonunion should be repaired with bone grafting and further internal fixation.
Malalignment of the subtalar joint in too much
varus results in locking of the transverse tarsal
joint and increased weight bearing on the lateral
side of the foot. To accommodate this, the
patient often walks with the extremity in external rotation.
If the subtalar joint is placed into excessive
valgus, it can impinge against the fibula, causing
pain over the peroneal tendons. It can also place
increased stress along the medial aspect of the
ankle joint and pronation of the foot.
Sural nerve entrapment or laceration can
occur and may be bothersome to the patient.
Unfortunately, the anterior branch of the sural
nerve can pass next to the incision, making
this complication almost unavoidable, but an
attempt should be made to identify it and
retract it if possible. If the neuroma is too bothersome it requires resection to a more proximal
level.
Authors Experience
We reviewed 101 of our subtalar arthrodeses
using the single lag screw method of fixation.
The average time for arthrodesis was 12.33.4
weeks. In the series, 99 of 101 fused (98%).6 The
presence of a prior ankle fusion significantly
prolonged the time to arthrodesis to 14.97
weeks. Other factors including smoking, revision surgery, patient age, or sex did not affect
time to arthrodesis. The fixation screw was
removed in 13 (13%) of 101, at an average of
8.8 months.
We reviewed another series of 48 subtalar
fusions in 44 patients (26 women and 18 men;
average age, 41.3 years; range, 13 to 75 years)

at an average of 60 months (range, 24 to 177


months) after surgery.8 The preoperative diagnosis was calcaneal fracture in 12 cases, talocalcaneal coalition in 11, subtalar joint arthrosis
without calcaneal fracture in 12 (5 primary, 7
post-traumatic), posterior tibial tendon dysfunction in 11, subtalar joint instability in one, and
psoriatic arthritis in one case.
Fusion occurred in 47 of 48 arthrodeses, with
the one nonunion in a young patient after a calcaneal fracture. This was successfully revised
using iliac crest bone graft. Sixteen (33%) of the
48 fusions underwent screw removal.
Forty-one patients (93%) were satisfied. The
three dissatisfied patients (7%) had persistent
pain; one foot was fused in 12 degrees of valgus
and another in 7 degrees of varus. The patients
observed a decrease in their pain from 3.7
out of 4.0 to 0.8 and a functional increase from
3.4 out of 4.0 to 0.9. Using the American
Orthopaedic Foot and Ankle Society (AOFAS)
scoring system,5 the patients averaged 89.3,
which translated to 86% good and excellent
results, 7% fair, and 7% poor.
Functionally the patients did well, although
half observed problems walking on uneven
ground and climbing steps and inclines. Seventy
percent participated in recreational sports (e.g.,
walking for pleasure, biking, skiing, swimming),
and 14% were able to play sports that required
running and pivoting (e.g., basketball, racquet
sports). This is a much higher level of activity
compared with patients who have undergone a
triple arthrodesis.3
Nine patients had work-related injuries; five of
these had a fracture of the calcaneus with resultant arthrosis. The two patients with bilateral fractures did not return to work, two were retrained
for a sedentary job, and one retrained for a construction job. Of the four other patients, three
returned to work and one retired.
All patients wore normal shoes, and six used
an orthotic device.
The physical examination demonstrated that
the alignment averaged 5.7 degrees of valgus,
and the one patient with fusion in varus was dissatisfied. The range of motion demonstrated an
average of 9.8 degrees of dorsiflexion compared with 14.2 degrees on the uninvolved side,
for a 30% loss of motion, and plantar flexion
averaged 47.2 degrees compared with 52.4
degrees, for a 9.2% loss of motion. This resulted
in a 14% loss of sagittal plane motion. The trans-

CHAPTER 20

verse tarsal joint motion demonstrated 60% loss


of abduction and adduction compared with the
uninvolved side. Five feet had flexible forefoot
varus with an average of 7 degrees, and six had
fixed forefoot varus with an average of 4.7
degrees.
Final follow-up radiographs demonstrated an
increase in arthrosis of the ankle joint in 12 of
33 patients; 11 of these had slight arthrosis (two
had mild symptoms), and one had moderate
changes and was symptomatic. Arthrosis
increased at the transverse tarsal joint in 13 of
33 patients, 12 had slight arthrosis, and only one
had mild symptoms. New osteophyte formation
along the anterior aspect of the ankle was noted
in 12 patients; five were slight (two symptomatic), five moderate (all were symptomatic),
and two severe (both symptomatic).
Evaluation of the subgroups demonstrated
that the 11 patients with a calcaneal fracture had
an AOFAS score of 83. Ten of the 11 underwent
an in situ fusion with lateral wall decompression.
One patient with severe collapse had a bone
block added to restore the height of the calcaneus. Based on our experience and that of
others,9,12 it is not necessary to add a bone block
when carrying out an isolated subtalar fusion
after a calcaneal fracture unless severe impaction exists with greater than 1.5 cm loss of
height (Fig. 201F).
The 10 patients who underwent a subtalar
arthrodesis for talocalcaneal coalition had an
average AOFAS score of 93. Six of these
patients had evidence of mild arthrosis of the
talonavicular joint at follow-up, but none were
symptomatic. Our study and another13 demonstrate that isolated subtalar fusion is the treatment of choice for a nonessential talocalcaneal
coalition. A triple arthrodesis is not necessary to
obtain a satisfactory result, even in the presence
of beaking of the talonavicular joint.
The eight patients with posterior tibial tendon
dysfunction had an AOFAS score of 88. This procedure was used when the primary deformity
was in the hindfoot with hindfoot valgus and
calcaneal impingement against the fibula or
when subtalar joint inversion was absent, precluding the use of a tendon transfer. These

Arthrodesis of the Foot and Ankle

1097

patients all had less than 12 degrees of fixed


forefoot varus and no transverse tarsal joint
hypermobility. A subtalar fusion is the procedure
of choice for these patients, because a tendon
transfer will fail owing to lack of subtalar inversion. A triple arthrodesis is not necessary and
creates a more rigid foot.
The five patients with primary arthrosis of the
subtalar joint that had not been previously
described in the literature had an AOFAS score
of 100. These patients did extremely well and
had essentially no limitations after their procedure. The other seven patients who had arthrosis of the subtalar joint not associated with a
calcaneal fracture but rather a talar fracture had
an AOFAS score of 86. This again demonstrates
that for an isolated subtalar joint problem, an
isolated subtalar joint arthrodesis results in satisfactory correction, and that a more extensive
fusion, with its increased long-term morbidity, is
not necessary.
Special Considerations
Occasionally in the patient with rheumatoid
arthritis, severe subluxation occurs at the subtalar joint (Fig. 201G and H). It is imperative that
the clinician recognize this problem so that
when a subtalar arthrodesis is carried out, the
calcaneus is repositioned under the talus, restoring the normal weight-bearing alignment. If the
surgeon fails to recognize this malalignment and
places a bone block into the lateral side of the
subtalar joint, wedging it open will not reposition the calcaneus into correct anatomic
alignment.
Sometimes following an ankle arthrodesis
patients develop arthrosis of the subtalar joint.
In this situation we carry out our standard type
of fusion. The screw placement is a little simpler
because there is no concern about penetrating
the ankle joint with the screw (Fig. 201I). Postoperatively these patients are placed into a
short-leg cast rather than a removable cast
because I believe better immobilization can be
achieved. We have not had problems achieving
an arthrodesis in this patient cohort, although it
does take longer to occur.

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PART V

Arthritis, Postural Disorders, and Tendon Disorders

TALONAVICULAR ARTHRODESIS

Surgical Technique

Although arthrodesis of the talonavicular joint


involves only a single joint, biomechanically it
results in almost complete loss of motion in the
subtalar and transverse tarsal joints. This motion
is lost because for the subtalar joint to invert and
evert, the navicular must rotate over the talar
head. Thus, if talonavicular movement is
restricted, subtalar motion does not occur.19,22
An isolated talonavicular arthrodesis results in
a satisfactory outcome, particularly in patients
who do not place a high demand on their foot,
such as rheumatoid patients.18,20 In the highdemand patient or one working at a strenuous
occupation, it is probably advisable to add a
calcaneocuboid joint arthrodesis. This creates a
double arthrodesis, resulting in increased stability of the transverse tarsal joint.17 The addition
of the calcaneocuboid joint to the talonavicular
fusion does not result in any further loss of hindfoot motion. Therefore, I usually carry out a
double arthrodesis instead of the isolated talonavicular arthrodesis, except in the low-activity
patient.

1. The patient is placed in the supine position,


and a thigh tourniquet is applied. Because
the extremity naturally falls into external
rotation, the patient does not require
turning.
2. The talonavicular joint is usually approached
through a longitudinal incision starting just
distal to the medial malleolus and carried
distally 1 cm beyond the naviculocuneiform
joint (Fig. 202B). The incision can be
curved slightly dorsally, particularly if a large
dorsal osteophyte requires removal.
3. Using a periosteal elevator or a sharp,
curved osteotome, the joint capsule is stripped from the dorsal, medial, and plantar
aspects of the joint.
4. If dorsal osteophytes are present, they are
removed at this time, using an osteotome
or a rongeur.
5. Exposure of the talonavicular joint is facilitated by placing a towel clip into the proximal medial portion of the navicular and
applying a distracting force in a medial
direction (Fig. 202C).
6. The articular surfaces of the talus and
navicular are identified, and the articular
cartilage is removed with an osteotome or
curet.
7. If the bone is hard enough, a small lamina
spreader sometimes can be placed into the
medial side of the joint to gain better visualization. This being a curved joint, visualization of the lateral aspect is difficult but
essential if satisfactory debridement is to be
achieved.
8. The joint surfaces are heavily feathered,
and the foot is manipulated into anatomic
alignment.
9. The calcaneus is held in one hand, placing the subtalar joint in approximately 5
degrees of valgus. The talonavicular joint is
manipulated, bringing the transverse tarsal
joint into a few degrees of abduction and
the forefoot into a plantigrade position that
is perpendicular to the long axis of the tibia.
If possible, the forefoot should not have a
residual of more than 5 to 7 degrees of fixed
forefoot varus or valgus.
10. The type of internal fixation selected
depends in part on the quality of the bone.
Using two 4.0- or 4.5-mm cannulated screws

Indications
The most common indication for an isolated
talonavicular arthrodesis is primary arthrosis,
arthrosis secondary to trauma,20 or rheumatoid
arthritis.18 With instability of the talonavicular
joint secondary to dysfunction of the posterior
tibial tendon or collapse of the talonavicular
joint from rupture of the spring ligament, an isolated talonavicular arthrodesis can be considered. In these circumstances, however, I usually
carry out a double or triple arthrodesis.
Alignment of the Fusion
The alignment of the normal foot is observed to
determine the alignment of the affected side.
The positioning of an isolated talonavicular
arthrodesis is very important, because the subtalar and calcaneocuboid joint motion is greatly
restricted after this arthrodesis. Therefore the
hindfoot and forefoot must be aligned into a
plantigrade position; if not, a nonplantigrade
foot will be created and may be symptomatic.
The subtalar joint should be placed into 5
degrees of valgus, the talonavicular joint into
neutral, and the forefoot into 0 to 5 degrees of
forefoot varus (Fig. 202A).

CHAPTER 20

Flatfoot deformity

1099

Long axis of talus passes


through first metatarsal

A1

Arthrodesis of the Foot and Ankle

A2

Figure 202 Talonavicular arthrodesis. A, Radiograph and diagram demonstrate changes that occur in the talonavicular joint
with flatfoot deformity. The head of the talus deviates medially as the forefoot deviates laterally into abduction. The diagram
demonstrates abnormal alignment brought about by flatfoot deformity and its subsequent correction. The navicular is once again
centered over the head of the talus. B, Exposure of the talonavicular joint through a medial incision. The Freer elevator points
to the naviculocuneiform joint. C, Access is gained to the talonavicular joint by distracting the joint with a towel clip.

1100

11.

12.

13.

14.

PART V

Arthritis, Postural Disorders, and Tendon Disorders

gives excellent fixation, and the profile of


the screw head is low enough that fracturing the medial aspect of the navicular need
not be a concern. In a large person a 7.0mm cannulated screw can be used. If the
bone is very soft, multiple staples are useful.
With the surgeon holding the foot in correct
alignment, a guide pin is placed starting
along the medial side of the navicular at
the naviculocuneiform joint and drilled
obliquely across the navicular into the head
and neck of the talus.
The alignment of the foot is then once again
carefully verified, and if it is satisfactory, the
pin placement is checked with fluoroscopy.
A second parallel pin is inserted.
The navicular is overdrilled and a 40- to
50-mm, long-threaded cancellous screw is
inserted. The smooth shank of the screw
must completely pass across the intended
fusion site. If the bone is soft, a washer is
used.
After both screws have been inserted, the
stability of the arthrodesis site is checked. If
any significant motion is present, staples
can be used to increase stability. This is
sometimes necessary in the rheumatoid
patient or the elderly patient with porotic
bone.

15. If the bone is too soft, four or five staples


are used for fixation. This is also useful if the
navicular fractures while inserting a screw
(Fig. 203).
16. The wound is closed in layers, with the deep
fascia being approximated over the arthrodesis site. The subcutaneous tissue and
skin are closed in a routine manner. The
wound over the talonavicular joint rarely
breaks down.
17. Bupivacaine is injected into the wound to
provide postoperative analgesia.
18. The patient is placed into a compression
dressing incorporating two plaster splints.
Postoperative Care
In the recovery room a popliteal block is administered to control postoperative pain. The postoperative dressing is changed in 10 to 14 days,
sutures are removed, and the patient is placed
into a short-leg, removable cast with an elastic
bandage to control swelling. Weight bearing
is not permitted. Six weeks after surgery,
radiographs are obtained, and if satisfactory
union is occurring, the patient is permitted to
ambulate with weight bearing as tolerated in
a short-leg cast. Three months after surgery, if
radiographic healing is evident, the patient is

Figure 203 Preoperative and postoperative radiographs demonstrate talonavicular arthrodesis using a 7.0-mm cannulated
screw. Note the congenital hallux varus.

CHAPTER 20

permitted to ambulate without support as


tolerated.
Complications
The nonunion rate of the talonavicular joint is
much higher than that of the calcaneocuboid or
subtalar joint, partly because of the surgeons
inability to gain adequate exposure of the entire
joint in preparation for the arthrodesis. The high
nonunion rate can also result from the relative
avascularity of the navicular, particularly in posttraumatic cases. If a nonunion occurs and the
alignment is satisfactory, carrying out a slot type
of bone graft into several areas around the
talonavicular joint usually results in satisfactory
union.
Malalignment of the joint results in malposition of the hindfoot and forefoot. The most
common malposition is a flatfoot deformity,
which results from leaving the forefoot in too
much abduction and the subtalar joint in valgus.
This can only be corrected by revision to a triple
arthrodesis.

DOUBLE ARTHRODESIS
The double arthrodesis as described by
DuVries23 consists of a fusion of the talonavicular and calcaneocuboid joints.17,24 It is based on
the biomechanical principle that if the motion in
the talonavicular and calcaneocuboid joints is
eliminated, no motion occurs in the subtalar
joint. This results in the same degree of immobilization as a triple arthrodesis, but without
the necessity of completing the subtalar
portion. A double arthrodesis takes less time
and probably has less patient morbidity because
the subtalar joint is not included in the fusion
mass.
Indications
The double arthrodesis is indicated when the
malalignment involves the transverse tarsal joint
or forefoot, or both. It is most often carried
out for patients with posterior tibial tendon dysfunction who are not candidates for a tendon reconstruction or subtalar fusion. In these
patients, the subtalar joint is flexible and no
subtalar disorder is present. There is also a

Arthrodesis of the Foot and Ankle

1101

fixed forefoot varus, greater than 15 degrees,


and abduction of the transverse tarsal joint
is increased. A fusion of the talonavicular and
calcaneocuboid joints is sufficient to create
a plantigrade foot without including the
subtalar joint. If any arthrosis is present within
the subtalar joint, a triple arthrodesis is
indicated.
The double arthrodesis is also indicated in
patients with isolated arthrosis involving the
talonavicular joint who, because of their young
age or high level of activity, would be placing
great stress on the foot. Although an isolated
talonavicular arthrodesis is excellent for the less
active patient (e.g., with rheumatoid arthritis), a
more active person often has some pain in the
foot if the calcaneocuboid joint is not added to
the talonavicular fusion. Based on my experience in large patients, rather than do a double
arthrodesis, a triple arthrodesis is a better procedure, because when a double arthrodesis is
carried out, great stress is placed on the talonavicular fusion site, which can result in fixation
failure and loss of alignment. When the subtalar
joint is added, creating a triple arthrodesis, it
stabilizes the subtalar joint, relieving stress on
the talonavicular joint.
Position of Arthrodesis
The positioning of the foot for a double
arthrodesis is extremely critical. The subtalar
joint must be placed into 5 degrees of valgus
and maintained there while the transverse
tarsal joint is positioned into the same degree
of abduction or adduction as the normal foot.
The forefoot is placed into a plantigrade
position with little or no residual fixed forefoot
varus. In many patients with dysfunction of
the posterior tibial tendon, one of the main
components being corrected is the fixed forefoot varus of greater than 15 degrees, which
precludes performing an isolated subtalar
fusion.
Surgical Technique
1. The patient is placed in a supine position
with a support under the ipsilateral hip to
allow easy access to the medial and lateral
aspects of the foot (video clip 12).
2. A thigh tourniquet is applied.
3. The skin incision is made along the lateral
aspect of the foot, starting at the base of

1102

4.

5.

6.
7.

8.

9.

10.

11.

12.

PART V

Arthritis, Postural Disorders, and Tendon Disorders

the fourth metatarsal, and extends proximally toward the tip of the fibula, stopping
about 1 cm short of the tip.
The incision is deepened to the extensor
digitorum brevis muscle. Care is taken to
identify any anterior branch of the sural
nerve that might be crossing the surgical
field.
The capsule of the extensor digitorum
brevis is opened, its origin is released, and
the muscle is reflected distally about 1 cm
distal to the calcaneocuboid joint.
The calcaneocuboid joint is identified and
the soft tissue stripped plantarward and
dorsally using a periosteal elevator.
The articular cartilage is removed from the
calcaneocuboid joint as thoroughly as possible using a small, sharp osteotome or
curet.
Placing a deep retractor into the wound
along the dorsal aspect, the surgeon identifies the lateral aspect of the talonavicular
joint opposite the calcaneocuboid joint
and removes articular cartilage if possible.
Usually, cartilage can be removed from the
lateral third of the talar head and occasionally from the navicular, depending on how
tight the foot is.
The medial approach is through a longitudinal incision, starting at the tip of the
medial malleolus and carried distally 1 cm
past the naviculocuneiform joint (see Fig.
202B).
The incision is deepened through the capsular tissues, after which the capsule and
spring ligament are stripped from the navicular. An elevator is passed over the dorsal
aspect of the talonavicular joint, completely
freeing the joint.
Using a towel clip embedded into the proximal portion of the navicular, the surgeon
distracts the talonavicular joint by pulling
the foot in an adducted position and longitudinally (see Fig. 202C). If the quality
of the bone is adequate, a small lamina
spreader is useful to gain exposure.
The articular cartilage is removed from the
talonavicular joint with an osteotome or
curet. Sometimes removing the cartilage is
difficult, and it is important to be sure that
the joint capsule has been completely
stripped from the talonavicular joint to facilitate exposure.

13. The foot is manipulated into proper alignment to determine whether any bone needs
to be removed from the attempted fusion
site, which generally is not necessary. However, it is important to be sure no gap is
created at the calcaneocuboid joint when the
foot is brought into a plantigrade position.
14. To correct a severe forefoot varus deformity,
the navicular must be plantar flexed on the
head of the talus. This is carried out by
holding the hindfoot in one hand and rotating the forefoot in such a way as to plantar
flex the navicular on the head of the talus
while simultaneously adducting the foot.
This maneuver corrects the deformity and
creates a plantigrade foot.
15. With the foot held in a plantigrade position, the calcaneocuboid joint is observed
because if it is distracted, some bone needs
to be removed from the talar head. This
does not occur often, but again, it is important that a gap is not created between the
calcaneus and cuboid.
16. Before placing the internal fixation, the
bone ends are heavily scaled using a 4-mm
osteotome. The talonavicular joint must be
well feathered from both medial and lateral
sides to ensure that the greatest amount of
bone surface has been destroyed to help
prevent a nonunion.
17. Many ways are available to carry out internal
fixation for a double arthrodesis. If adequate
bone stock exists, two 4.0-mm cannulated
screws across the talonavicular joint provides
excellent internal fixation. A single 7.0-mm
screw can be used in a large patient, but in
a smaller person or a person with soft bone,
it can result in a fracture of the medial side
of the navicular (Fig. 204A to C).
18. The foot is then manipulated into proper
alignment as described earlier; and the
guide pin for the 4.0-mm cannulated screw
is placed across the talonavicular joint.
19. The guide pin is started at the distal end of
the navicular at the naviculocuneiform joint.
If one starts at the midportion of the navicular, insufficient bone may be present along
the medial side of the navicular, and a fracture of the medial aspect of the navicular
can occur. The surgeon should attempt to
incorporate as much of the medial aspect
of the navicular as possible with the screw.
The placement is usually checked with

B3
B1

B2

C2

C1

D1

D2

Figure 204 A, Diagram of double arthrodesis. B, Preoperative and postoperative radiographs demonstrating arthrodesis using
7-0 mm cannulated screws. C, Double arthrodesis using a cannulated screw for the talonavicular joint and power staples for the
calcaneocuboid joint. D, Double arthrodesis using power staples in both the talonavicular and calcaneocuboid joints. This is
done when the bone is soft, particularly in a patient with rheumatoid arthritis. Note the arrangement of staples around the joint
to gain maximum stabilization.
Continued
1103

1104

PART V

Arthritis, Postural Disorders, and Tendon Disorders

E2

E1

F1
F2

G3

G1

G2
G4

Figure 204contd E, Radiographs demonstrate failed double arthrodesis secondary to fracture of the talonavicular screw.
F, Revision of double arthrodesis to a triple arthrodesis. G, Preoperative and postoperative radiographs demonstrate the correction that can be obtained with double arthrodesis in a patient with an acquired flatfoot secondary to posterior tibial tendon
dysfunction.

CHAPTER 20

fluoroscopy, and if placement is satisfactory,


a parallel pin is inserted. The navicular is
overdrilled with a 4.0-mm drill bit, after
which 4.0-mm long threaded screws are
inserted. It is important that the threads
cross the joint surface. If the quality of bone
is not good, washers should be employed.
20. The fixation of the calcaneocuboid joint
is usually carried out using two 4.0-mm
cannulated screws. As a general rule, the
screws can be brought from proximal to
distal, starting in the anterior process
area and brought obliquely across into the
cuboid. At times, however, the bone alignment is such that this is not possible, and
the screws are brought from the cuboid into
the calcaneus. Sometimes the bone is
too soft, and a seam of staples is used
(Fig. 204D).
21. The deep layers are closed, followed by the
subcutaneous tissues and skin.
22. The wounds are instilled with 0.25% bupivacaine, after which a compression dressing
incorporating plaster splints is applied.
Postoperative Care
In the recovery room a popliteal block is administered to control postoperative pain. The postoperative dressing is removed in approximately
10 days, after which the patient is placed into a
removable cast with an elastic bandage to
control swelling. The patient is kept nonweight
bearing for 6 weeks from the time of surgery. At
6 weeks, radiographs are obtained. If satisfactory union is occurring, the patient is permitted
to bear weight in a cast. Approximately 12
weeks after surgery, radiographs again are
obtained. If satisfactory union has occurred, the
patient is permitted to ambulate with an elastic
stocking .
Authors Experience
We reviewed our experience with 32 patients
(19 women, 13 men) who had undergone a
double arthrodesis.25 The average age was 62
years (range, 38 to 81 years), and average
follow-up was 56 months (range, 24 to 162
months). The diagnosis was posterior tibial
tendon dysfunction in 20 patients, isolated
talonavicular arthrosis in five, rheumatoid arthritis in five, talar neck nonunion in one, and an
acquired flatfoot deformity after a spinal cord
injury in one.

Arthrodesis of the Foot and Ankle

1105

The patients satisfaction rate was 92%, and


8% were dissatisfied. Pain relief was the main
benefit. The preoperative pain, assessed as 4.3
of a possible 5, diminished postoperatively to
1.4 (zero equals no pain). Functional capacity
increased from 3.6 of 4 preoperatively to 1.3
postoperatively.
The fusion rate was 87.5% (28 of 32 cases).
Four nonunions of the talonavicular joint
occurred, all of which had staple fixation. Three
of the four required a revision to a triple
arthrodesis (Fig. 204E and F).
As a group, they noted maximum recovery at
about 8 months after surgery.
The patients level of activities demonstrated
that most could walk for pleasure, and five were
able to run short distances; 60% played golf,
biked, hiked, and swam. Seventy-five percent of
the patients noted some difficulty when walking
on uneven ground or inclines or when going up
and down steps.
The physical examination demonstrated that
the average hindfoot position was 5.8 degrees
of valgus, the transverse tarsal joint had 4.4
degrees of abduction, and the forefoot varus
was 9 degrees. The range of motion of the ankle
joint decreased 11 degrees compared with the
uninvolved side.
The radiographic evaluation demonstrated
that the anteroposterior (AP) talarsecond
metatarsal angle improved from 30 degrees
(abduction) to 14 degrees, and the lateral
talarfirst metatarsal angle improved from 16
degrees (indicating dorsiflexion) to 7 degrees
postoperatively (Fig. 204G).
The follow-up radiographs demonstrated a
slight degree of ankle arthrosis in 53% of
patients that was not present preoperatively,
and 30% noted mild symptoms. Twenty percent
demonstrated evidence of arthrosis in the subtalar joint, but none were symptomatic. The naviculocuneiform joint demonstrated an increase
in arthrosis in 37% of patients, all of whom had
slight symptoms, except for one patient, whose
symptoms were severe. The tarsometatarsal
joints demonstrated a 22% increased incidence,
but none were symptomatic.
Special Considerations
Complex problems involving the talonavicular
joint include its possible collapse secondary to
fracture, avascular necrosis, or both. At other
times, involvement of the forefoot distal to the

1106

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Arthritis, Postural Disorders, and Tendon Disorders

talonavicular joint occurs, with extension into


the naviculocuneiform and sometimes the tarsometatarsal joints. In these situations a modified double arthrodesis has been used to
provide stability.
In many of these cases the overall alignment
of the foot is satisfactory or at least adequate for
a plantigrade foot. Rather than take down the
involved areas and place a large bone graft, a
rectangular slot is cut from the talus to the
cuneiforms or into the metatarsal bases, as indicated by the clinical circumstances (Fig. 205).
The slot is cut all the way across the foot from
medial to lateral, after which a piece of iliac crest
bone graft is inlaid into the slot. Fixation of the
bone graft and surrounding bone is done with
screws or multiple staples. At the same time the
calcaneocuboid joint is arthrodesed to provide
stability to the lateral column. This is obviously

an extensive procedure and is only done under


certain circumstances when significant deformity
within the midportion of the foot is present but
no significant anatomic correction needs to be
carried out. In a situation with marked destruction of the midfoot and malalignment, this procedure cannot be used. Then one would need
to take down the involved area and either bone
graft it or possibly collapse the lateral column to
realign the midfoot.
After the inlay bone graft procedure, the
patient is immobilized for a prolonged period.
As a general rule, weight bearing is not permitted for 3 months, after which the patient is gradually started on progressive weight bearing over
the next 3 months. It is sometimes difficult to
state when union has occurred, and therefore
the surgeon should be very cautious in allowing
patients to bear weight.

Figure 205 Technique for slot graft to correct disruption of tarsal joints. A, Outline of slot graft extending from the talus into
the metatarsal bones. B, Preoperative and postoperative radiographs demonstrate placement of the bone block, which is held
in place with two 4.0-mm screws, and fusion of the calcaneocuboid joint to help reinforce the fusion site. Preoperative and postoperative anteroposterior (C) and oblique (D) radiographs demonstrate placement and incorporation of the bone block.

CHAPTER 20

TRIPLE ARTHRODESIS

Arthrodesis of the Foot and Ankle

1107

ative period to remanipulate the foot into better


alignment.
As the number of patients with deformed
feet secondary to paralysis declined, the triple
arthrodesis was performed less often. It is now
most often carried out for residuals of trauma,
rheumatoid arthritis, and long-standing posterior tibial tendon dysfunction in which the basic
bone anatomy is present. Although distorted,
significant bone resection is usually not necessary. This allows the procedure to be done by
releasing the contracted joint capsules, removing the articular cartilage, scaling the exposed

The triple arthrodesis consists of fusion of the


talonavicular, calcaneocuboid, and subtalar
joints (Fig. 206A). Initially the triple arthrodesis
was used to treat deformities of the foot
secondary to paralysis, mainly poliomyelitis,
in which severe anatomic distortion was present.33,35,38 To correct this abnormality, large
bone wedges were resected to place the foot
into a plantigrade position. Little or no internal
fixation was used, and at times the patient was
returned to surgery in the immediate postoper-

D1

D3
C1
B1

D2

D4

B2
C2
Figure 206 Triple arthrodesis, methods of internal fixation. A, Diagram of triple arthrodesis. B, Postoperative radiograph
demonstrating triple arthrodesis with anatomic restoration of foot posture. C, Triple arthrodesis using 7.0-mm cannulated screws
for the subtalar and talonavicular joints and multiple power staples for the calcaneocuboid joint. D, Correction of severe hindfoot deformity secondary to long-standing posterior tibial tendon dysfunction with restoration of the longitudinal arch using a
7.0-mm cannulated screw for the subtalar joint and power staples for the talonavicular and calcaneocuboid joints. Note that the
height of the longitudinal arch has been restored and severe abduction of the foot is corrected.

1108

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Arthritis, Postural Disorders, and Tendon Disorders

bony surfaces, and using manipulation to create


a plantigrade foot. It is not unusual to carry
out a triple arthrodesis when no distortion of
the anatomy exists, and an in situ fusion is
achieved.32
The best way to carry out a triple arthrodesis
is by meticulously releasing the joint capsules to
mobilize the joint; removing the articular cartilage; scaling or feathering the bone surfaces;
aligning the foot into a plantigrade position;
and securing the joints with rigid internal fixation. By using these principles, a high fusion rate
and a plantigrade foot can be achieved. In our
experience, bone grafting from the iliac crest is
rarely necessary, but if bone graft is needed, it
can usually be obtained from the calcaneus,
medial malleolus, or proximal tibia without
violating the iliac crest and risking added
morbidity.
Although the triple arthrodesis is a valuable
tool for the orthopaedic surgeon, it is not
without postoperative complications. The literature points out that because of the added
stress across the ankle joint as a result of a
triple arthrodesis, approximately 30% of patients demonstrate ankle degeneration at 5
years.26-31,36-38 This reinforces the biomechanics
of the foot and ankle complex, demonstrating
that the ankle, subtalar, and transverse tarsal
joints are functioning together. When a triple
arthrodesis is carried out, increased stress is
placed proximally on the ankle joint and distally
on the midfoot. Therefore it is imperative that a
more limited arthrodesis always be considered
when feasible. Because of the possible ankle
joint deterioration, when evaluating the patient
preoperatively for a triple arthrodesis, a weightbearing AP radiograph of the ankle must be
included to ascertain if preexisting arthrosis can
preclude the triple arthrodesis or at least to
predict the future for the patient.
Indications
Arthrosis involving the subtalar joint and either
the talonavicular or the calcaneocuboid joint, or
both, is an indication for triple arthrodesis.
Arthrosis of only the subtalar joint can usually be
treated by an isolated subtalar joint fusion.
Triple arthrodesis can be used for the unstable hindfoot secondary to neuromuscular disorders such as poliomyelitis, nerve injury, posterior
tibial tendon dysfunction, or rheumatoid arthri-

tis in which the subtalar and transverse tarsal


joints are involved. Malalignment of the foot
secondary to arthrofibrosis resulting from a
compartment syndrome, crush injury, or severe
trauma is an indication for a triple arthrodesis.
In the patient with a symptomatic, unresectable,
or previously resected calcaneonavicular coalition, a triple arthrodesis is indicated. It is
important to appreciate, however, that the
patient with a talocalcaneal (subtalar) coalition
can be treated with an isolated subtalar fusion
even if there is osteophyte formation on the
dorsal aspect of the talar head. The patient
with a severe symptomatic pes planus deformity
that is not amenable to other procedures,
such as lateral column lengthening, calcaneal
osteotomy, or subtalar fusion, can also be considered a candidate for a triple arthrodesis.
Whenever considering a triple arthrodesis,
however, the surgeon must be mindful of the
consequences of the potential degeneration at
the ankle joint. If a younger person can be
treated with an AFO or a more limited fusion,
this may be a better method of treatment.
Position of Arthrodesis
The position of a triple arthrodesis is critical
because once an arthrodesis has been achieved,
the foot is in a fixed position and cannot accommodate to the ground. It is therefore essential
that the hindfoot be placed in about 5 degrees
of valgus, the transverse tarsal joint in 0 to 5
degrees of abduction, and the forefoot in less
than 10 degrees of varus. If accurate alignment
is not achieved, the patient will have a nonplantigrade foot, which can cause chronic pain
that requires a revision.
Surgical Technique
1. The normal foot is examined and its
alignment noted. Patients have a varying
degree of forefoot adduction or abduction,
and the surgeon should attempt to match
this with the affected extremity (video clip
14).
2. The patient is placed in a supine position
with a support under the ipsilateral hip to
improve visualization of the lateral aspect of
the hindfoot. (A detailed discussion of this
approach is presented in the sections on
subtalar and double arthrodeses.)

CHAPTER 20

3. The skin incision starts at the tip of the fibula


and is carried to the base of the fourth
metatarsal. Caution should be used when
deepening this incision, looking for the sural
nerve and possibly an anterior branch (see
Fig. 201A).
4. The extensor digitorum muscle is removed
from its origin on the lateral side of the talus
and calcaneus and retracted distally.
5. The subtalar and calcaneocuboid joints
are visualized, and the articular cartilage is
removed.
6. Through the lateral incision, the lateral
aspect of the talonavicular joint is identified
and as much articular cartilage is removed
as possible. (A detailed discussion of this
approach is presented in the section on
talonavicular arthrodesis.)
7. The skin incision begins 2 cm distal to the
tip of the medial malleolus in the midline
and is carried 1 cm distal to the naviculocuneiform joint (see Fig. 202B).
8. The incision is deepened to expose the joint
capsule, which is stripped from the talonavicular joint.
9. Using a towel clip in the navicular, the
surgeon distracts the joint by pulling the
foot into an adducted position to enhance
visualization of the articular surfaces (see
Fig. 202C). If the bone stock is adequate,
a small lamina spreader is useful.
10. The articular cartilage is removed from the
talonavicular joint.
11. At times, some articular cartilage is also
removed through the lateral incision. This
depends on the flexibility of the foot.
12. The foot is manipulated, first by bringing
the subtalar joint into 5 degrees of valgus,
then manipulating the transverse tarsal joint
to eliminate the fixed forefoot varus. This is
done by rotating the navicular in a plantar
direction on the head of the talus and simultaneously bringing the transverse tarsal joint
into about 0 to 5 degrees of abduction. This
maneuver usually creates a plantigrade
foot. The foot cannot be manipulated
if the joints have not been completely
mobilized.
13. After the manipulation, it is important to
inspect the articular surfaces to be sure
there is good bone apposition. If the bones
are not properly apposed, it may be necessary to remove some bone, usually from the

14.
15.
16.

17.

18.

19.

20.

21.

22.

23.

Arthrodesis of the Foot and Ankle

1109

head of the talus, to shorten the medial


column and close the calcaneocuboid joint.
Once alignment has been achieved, the
joint surfaces are heavily scaled or feathered
in preparation for internal fixation.
The internal fixation is initially achieved in
the subtalar joint (see the section on subtalar arthrodesis and Fig. 201D).
The anterior cruciate guide is placed into
the posterior facet of the subtalar joint and
then the back of the heel. A guide pin is
inserted into the posterior facet and the AO
guide is removed.
The calcaneus is manipulated into 5 degrees of valgus, and the pin is advanced
into the neck of the talus. Its position is verified by fluoroscopy.
The length of the screw is determined
and the guide pin is drilled through to
present on the dorsal aspect of the ankle
joint.
A 4.5-mm cannulated drill is used to make
the initial hole, which must pass through the
anterior cortex of the talus, after which the
calcaneus is overdrilled with a 7.0-mm bit.
The talar neck is tapped and a 7.0-mm fully
threaded cannulated screw with a washer is
inserted. This fixes the subtalar component
of the triple arthrodesis in correct alignment. In our experience, a single screw is
adequate to stabilize the subtalar joint.
The transverse tarsal joint is manipulated to
correct the forefoot malalignment. Once the
appropriate alignment has been achieved,
the talonavicular joint is fixed.
The fixation of the talonavicular joint is
usually achieved with two 4.0-mm cannulated screws. The guide pin is inserted
across the talonavicular joint, starting at
the naviculocuneiform joint, and is driven
obliquely into the neck of the talus. Two
guide pins are inserted and their position is
verified radiographically.
The navicular is overdrilled with a 4.0-mm
drill bit, and a partially threaded cannulated
screw of appropriate length is inserted; a
washer may be used depending upon bone
quality. The screws generally are about 45
to 60 mm in length, but this varies from
patient to patient.
The calcaneocuboid joint is visualized and
fixed with two 4.0-mm cannulated screws.
The guide pin is placed from the calcaneus

1110

24.
25.

26.
27.

PART V

Arthritis, Postural Disorders, and Tendon Disorders

into the cuboid, and two partially threaded


screws of appropriate length are used. If the
bone is too soft, staples are used.
If the surgeon is not satisfied with the coaptation of the bony surfaces, a bone graft can
be used if necessary.
The extensor digitorum brevis muscle is
closed over the lateral side of the wound,
after which the subcutaneous tissue and
skin are closed. On the medial side, the
capsular tissue is closed over the talonavicular joint, if possible, after which the subcutaneous tissue and skin are closed.
Bupivacaine (0.25%) is instilled into the
wound to provide initial postoperative
analgesia.
A compression dressing incorporating two
plaster splints is applied.

Postoperative Care
In the recovery room, a popliteal block is administered to control the immediate postoperative
pain. The patients initial surgical cast is changed
10 to 14 days after surgery, and the sutures are
removed if appropriate. The patient is placed
into a short-leg removable cast with an elastic
bandage to control edema and is kept non
weight bearing for 6 weeks. Then radiographs
are obtained, and if satisfactory union is occurring, the patient is permitted to bear weight as
tolerated in the removable cast.
Twelve weeks after surgery, radiographs are
again obtained, and if a fusion has occurred,
the patient wears an elastic stocking and is
permitted to bear weight as tolerated. If the
fusion is somewhat tenuous, the patient is asked
to walk around the house without the cast and
use it outside for another month (Fig. 206B
to D).
Complications
The most frequent complication after a triple
arthrodesis is a nonunion of one of the fusion
sites, most often the talonavicular joint, probably because its exposure is more difficult and the
bone may be sclerotic. If a nonunion occurs and
is not symptomatic, no treatment is indicated.
Occasionally after a triple arthrodesis, if two of
the three joints have fused, the joint with a
nonunion is asymptomatic. If a painful nonunion
is present but the alignment of the extremity is
satisfactory, some type of an inlay bone block

across the area of the nonunion, possibly along


with reinforcement of the internal fixation,
usually results in a satisfactory fusion. If the area
of the nonunion is symptomatic and the alignment is unsatisfactory, revision of the arthrodesis may be necessary.
The next most common complication is
malalignment. In my experience the most frequent malalignment is residual varus of the calcaneus, followed by a fixed forefoot varus and
then adduction of the forefoot. A valgus deformity of the hindfoot, although not as common
as a varus deformity, is distressing for most
patients and can result in an unsatisfactory
outcome.31,35 In this situation the surgeon might
consider a medial displacement calcaneal osteotomy to correct the excessive valgus if
the remainder of the forefoot alignment is
satisfactory.
Entrapment of the sural nerve, particularly an
anterior branch, giving rise to dysesthesias on
the lateral side of the foot, can annoy the
patient. This might need to be corrected by
a neurolysis or resection of the nerve, then
burying the stump under soft tissues or into
bone.
Occasionally after a triple arthrodesis in a
patient with long-standing severe valgus deformity, although a plantigrade position of the foot
can be achieved, the ankle cannot be brought
back to neutral position because of an Achilles
tendon contracture. When the triple arthrodesis
is carried out, if the ankle cannot be brought
into about 5 degrees of dorsiflexion, an Achilles
tendon lengthening or gastrocnemius slide
should be strongly considered. One must be
cautious, however, not to overlengthen the
tendon, but the foot should not be left in
an equinus posture. Adults recover their
strength very slowly, if at all, after Achilles
tendon lengthening.
Revision for Malalignment
A plantigrade foot might not be achieved after
a triple arthrodesis. If the patient is symptomatic, a revision of the triple arthrodesis may be
indicated. Technically these are very difficult
cases and need to be carefully planned preoperatively to identify the precise nature and
degree of the malalignment and which components of the triple arthrodesis need to be
revised.

CHAPTER 20

If the hindfoot is malaligned and the forefoot


is in a plantigrade position, the hindfoot can be
corrected without revising the forefoot. If a varus
deformity is present, a lateral closing wedge
Dwyer procedure can be used. Occasionally
a lateral displacement osteotomy with some
rotation of the fragment from varus into valgus can produce better alignment.
When the calcaneus is in too much valgus and
there is an impingement against the fibula, a
calcaneal osteotomy displacing it in a medial
direction can be used to correct the deformity.
However, rather than create a long oblique
osteotomy, as one would for a Dwyer procedure, the cut is made more perpendicular, just
posterior to the posterior facet of the subtalar
joint. The osteotomy is then displaced medially
about 1 cm, and occasionally the posterior fragment can be rotated slightly on its long axis if
the degree of valgus has a rotational component. Fixation of the osteotomy is usually done
with a cannulated 7.0-mm screw placed just
lateral to the Achilles tendon and driven distally
across the osteotomy site into the calcaneus. If
one screw is not adequate for fixation, a Steinmann pin is used for 4 weeks until the bones
have become sticky.
If the hindfoot is properly aligned and the
main deformity is malalignment of the forefoot,
usually from residual forefoot varus, the front
portion of the triple arthrodesis can be revised
and the hindfoot left intact. Besides the varus
deformity, an adduction deformity is also often
present. This type of revision is carried out
through a medial and lateral approach through
the previous incisions. The soft tissues are
stripped off the fusion mass around the transverse tarsal joint, which is osteotomized, and the
foot is realigned. The realignment is usually
carried out by rotating the forefoot block of
bone into a more pronated position. If there is
residual adduction or possibly abduction in the
forefoot, a lateral or medial closing wedge is
removed at the same time to achieve satisfactory alignment. Fixation after a revision can
usually be achieved by using large screws, but
if the bone is too soft, multiple staples can be
useful.
The postoperative regimen after revision of
a triple arthrodesis is the same as for a
triple arthrodesis, that is, nonweight bearing
for 6 weeks and then weight bearing for 6
weeks.

Arthrodesis of the Foot and Ankle

1111

Authors Experience
We have reviewed two groups of patients after
triple arthrodesis.30,34 The first group involved 29
fusions in 27 patients (23 women, 4 men) for
treatment of posterior tibial tendon dysfunction.
The average age was 62 years (range, 44 to 78
years), and average follow-up was 55 months
(range, 24 to 122 months). The preoperative
AOFAS score was 30, which improved postoperatively to 80. One nonunion of the talonavicular joint occurred and was asymptomatic.
The AP radiographs demonstrated that the
talarfirst metatarsal angle improved from
24 to 10 degrees postoperatively and the
talarsecond metatarsal angle from 35 to 19
degrees. In the lateral radiograph the talar
first metatarsal angle improved from 18 to 9
degrees. In all cases the final correction was
greater than the contralateral foot if it was not
pathologic. The radiographs further demonstrated an increase in the arthrosis in the ankle
joint in 10 of 29 cases (33%), in the naviculocuneiform joint in five (17%), and at the tarsometatarsal joint in four (14%) (Fig. 207A
and B).
A second group consisted of 17 patients (12
women, 5 men) and 18 feet, with an average
age of 66 years (range, 52 to 80 years ). They
were evaluated to determine the effect of a
triple arthrodesis in the older age group,
because no paper had previously addressed this
in the literature.30 The etiology was posterior tibial tendon dysfunction in 10 patients,
rheumatoid arthritis in three (four feet), diabetes
mellitus in one, poliomyelitis in one, trauma in
one, and poststroke effects in one. The followup was 42 months (range, 27 to 156 months).
The procedure was carried out because of pain,
deformity, or both. The pain level preoperatively
was 4 on a scale of 5 and postoperatively
was 1.
Fourteen patients (15 feet) were satisfied
because of the improved position and diminished pain. Interestingly, however, 11 patients
still thought they had some pain in the foot,
but it was not sufficiently symptomatic for them
to be dissatisfied with the procedure. Of the
three patients who were dissatisfied, two had
a valgus alignment of the heel that resulted
in pain. The patients observed that the time
from surgery to maximum relief was about 10
months.

1112

PART V

Arthritis, Postural Disorders, and Tendon Disorders

The level of activities improved for nine


patients (10 feet). Seven reported no change in
their ambulatory capacity, and one believed that
her ambulatory capacity was decreased. The
appearance of the foot improved for 13 of 17
patients, and two were dissatisfied because of
the valgus alignment of their heel. Twelve
patients (13 feet) could wear any shoe they
wanted, but five had some problems with
footwear.
The range of motion demonstrated that dorsiflexion was equal on both feet, and plantar
flexion on the affected side was 30 degrees
compared to 44 degrees on the normal side, for
a 32% loss.
Radiographs demonstrated that the AP
talarsecond metatarsal angle improved from
36 to 16 degrees and the lateral talarfirst
metatarsal angle from 22 to 9 degrees, which
indicates plantar flexion of the first metatarsal.
Some evidence of arthrosis of the ankle joint
was seen preoperatively in 14 of the 18 ankles
and progressed in seven (one grade in three
ankles and greater than one grade in four).
Seven patients demonstrated changes at the
naviculocuneiform and tarsometatarsal joints.
Three nonunions occurred, one at the talonavicular joint, which was revised successfully,

Figure 207 A, Mild valgus tilt of the


ankle joint 2 years after triple arthrodesis. B, Moderate valgus tilt 3 years after
triple arthrodesis.

and two at the calcaneocuboid joint, one requiring revision and one being asymptomatic.
In summary, the triple arthrodesis is an excellent procedure for correcting a fixed deformity
of the foot, but it should be used judiciously,
particularly in the younger patient, and only
when a lesser procedure cannot be used.

NAVICULOCUNEIFORM ARTHRODESIS
A naviculocuneiform arthrodesis is usually
carried out for arthrosis of one or more of the
articulations as a result of primary arthrosis or
secondary to trauma. The other reason to carry
out this arthrodesis is in the patient with posterior tibial tendon dysfunction and a fixed forefoot varus deformity so that a more extensive
hindfoot fusion can be avoided.
In the patient with a fixed uncorrectable
forefoot varus deformity, a double or triple
arthrodesis is indicated because an isolated subtalar arthrodesis would cause the patient to walk
on the lateral border of the foot. If the fixed fore-

CHAPTER 20

foot varus can be corrected, however, patients


with this deformity can be treated with a subtalar arthrodesis and a naviculocuneiform
arthrodesis. This spares the transverse tarsal
joint, which leaves the forefoot more flexible.
Approximately 15 to 20 degrees of fixed forefoot varus can be corrected through the naviculocuneiform joint, depending upon how rigid
the deformity is.
Indications
The most common indication is isolated naviculocuneiform arthrosis secondary to trauma. The
next most common indication is a fixed forefoot
varus deformity secondary to posterior tibial
tendon dysfunction.
Position of Arthrodesis
With arthrosis of the joint secondary to trauma
there usually is little or no deformity of the forefoot, and an in situ fusion can be carried out.
Because this is a difficult articulation to obtain
an isolated arthrodesis, the fusion mass should
include the first and second and, if possible,
the third naviculocuneiform joints. When there
is a fixed forefoot varus, the position of the
arthrodesis depends upon the degree of deformity. Arthrodesis is usually carried out along
with either a subtalar arthrodesis or a reconstruction of the posterior tibial tendon with an
FDL transfer.
Surgical Technique
1. The patient is placed in the supine position,
and a thigh tourniquet is applied. Because
the extremity naturally falls into external
rotation, the patient does not require
turning.
2. The naviculocuneiform joint is approached
through a longitudinal incision starting just
distal to the medial malleolus and carried
distally just dorsal to the posterior tibial
tendon, distal enough to expose the first
metatarsocuneiform joint.
3. The dissection is carried down to bone,
using caution not to injure the posterior
tibial tendon as it passes on the plantar
aspect of the wound. As one proceeds distally, the tibialis anterior tendon is obliquely
crossing the field and needs to be mobilized
so that it can be pulled somewhat distally
out of harms way.

Arthrodesis of the Foot and Ankle

1113

4. By sharp and blunt dissection the joint


capsule is stripped from the medial, dorsal,
and plantar aspects of the joint.
5. Using a small osteotome, the articular cartilage is removed from the first, second, and
third cuneiform, as well as the corresponding surface of the navicular. Usually it is
difficult to completely denude the third
naviculocuneiform joint. A small lamina
spreader does help facilitate exposure of
these joints.
6. The articular surfaces are then feathered
with a 4-mm osteotome or perforated with
multiple drill holes.
7. The foot is corrected by rotating the distal
portion of the foot into pronation or plantar
flexion at the fusion site while holding the
hindfoot in neutral position. Sometimes it
takes several manipulations in this manner
to gain the necessary correction. It is important, however, that as this is carried
out the hindfoot is held in neutral position,
otherwise inadequate correction will be
obtained. If correction of the deformity
seems overly difficult, it is probably due to
lack of adequate capsular stripping.
8. Once the foot is manipulated into satisfactory alignment, a 0.062-inch Kirschner wire
is placed across the dorsal aspect of the
joint to stabilize it so that internal fixation
can be inserted.
9. Rigid fixation can be achieved by placing
the screws from the tubercle of the navicular and proceeding distally into the first and
second cuneiforms. A third screw passing
from the first cuneiform back into the navicular can also be used with caution. The
problem with the screw passing in this direction is that all the threads have to pass
across the fusion site and cannot enter the
talonavicular joint.
10. Usually one screw is passed from the navicular into the first cuneiform and the second
from the navicular into the second cuneiform. As a rule, it is not possible to get a
screw from the navicular into the third
cuneiform.
11. The wound is closed in layers, with the deep
fascia being approximated over the fusion
site. The subcutaneous tissue and skin are
closed in a routine manner. Wounds along
the medial border of the foot usually heal
well.

1114

PART V

Arthritis, Postural Disorders, and Tendon Disorders

Postoperative Care
A popliteal block is administered by anesthesia
to control postoperative pain. The postoperative dressing is changed in 10 to 14 days,
sutures are removed, and the patient is placed
into a short-leg removable cast with an elastic
bandage to control swelling. Weight bearing is
not permitted until 6 weeks after surgery. At 6
weeks following surgery, if x-rays demonstrate
early union, the patient is permitted to bear
weight as tolerated in a short-leg removable
cast. As a general rule, the arthrodesis occurs
after about 3 months.

Complications
Nonunion of the naviculocuneiform joints does
occur, but by including at least the first and
second joints along with the internal fixation
passing from the tubercle of the navicular into
the cuneiforms, satisfactory union seems to
occur in most cases (Fig. 208).
The other complication is incomplete correction of the fixed forefoot varus in the patient
with posterior tibial tendon dysfunction. If
malalignment is still present and results in
a nonplantigrade foot, a double or triple
arthrodesis might be necessary to create a
plantigrade foot.

TARSOMETATARSAL ARTHRODESIS
Arthrodesis of the tarsometatarsal joints can
involve an isolated joint, usually the second or
third, or it can involve multiple joints, depending on the etiology of the arthrosis. As a general
rule, patients with primary arthroses usually have
fewer joints that require fusing than those with
post-traumatic arthrosis. In our study of 41 feet,
we observed that the patient with posttraumatic arthrosis had an average of six joints
fused per foot, compared with four joints per
foot in the primary arthrosis group.41

Figure 208 Preoperative (A and B) and postoperative (C


and D) radiographs of a naviculocuneiform arthrodesis to
correct a forefoot varus deformity. Note the placement of
screws from the navicular into the cuneiforms. The fusion mass
should include the navicular and at least cuneiforms 1, 2, and
3, if possible.

CHAPTER 20

The extent of the deformity is also variable.


This depends on the number of joints involved
and whether the deformity results from primary
or traumatic arthrosis. The patient with primary
arthrosis tends to have more pronation and a
greater degree of deformity. Usually, if a single
joint is involved, particularly the second or third,
little or no deformity is present and therefore
only an in situ fusion is necessary. If a deformity
is present, however, realignment of the foot is
essential to obtain a satisfactory result.
Determining the extent of the fusion site is
sometimes difficult, particularly if it appears as
though only one joint is involved. Besides a
careful physical examination and radiographic
studies consisting of weight-bearing radiographs, a computed tomography (CT) scan
and bone scan may be useful in determining the
extent of the arthrosis and which joints should
be included in the fusion mass. Even after
careful physical and radiographic evaluation, if
any doubt exists regarding the presence of
arthrosis, the joint should be examined at
surgery to be sure that arthritis is not being
overlooked. Arthrosis may be seen at surgery
when, even in retrospect, the radiograph
appears to be normal. This is particularly true for
the medial naviculocuneiform joint and the third
metatarsocuneiform (MTC) joint. Although the
most obvious arthrosis usually is present at the
tarsometatarsal or intertarsal joints, the naviculocuneiform joints must always be carefully
evaluated, particularly in the patient after
trauma. If the naviculocuneiform joint does
appear to be involved, at least the two medial
joints should always be included in the fusion
mass and, if necessary, the third. It is difficult to
obtain an isolated fusion between the medial
cuneiform and the navicular.
The question is often raised about whether
the fourth and fifth metatarsocuboid articulations should be included in the fusion site or
if they should undergo isolated fusion. As a
general rule, the fourth and fifth metatarsocuboid articulations seem to be somewhat
more forgiving and tend to be less symptomatic
than the medial three MTC joints, despite the
arthrosis. The reason may be that more flexibility exists in the two lateral rays than in the
medial three rays, which are more rigid. Motion
also occurs between the third cuneiform and
cuboid, which results in more motion of the two
lateral rays of the foot. If clinical examination

Arthrodesis of the Foot and Ankle

1115

and radiographs show arthrosis at the fourth and


fifth metatarsocuboid joints and a fusion is indicated, however, the cuboid should not be fused
to the lateral cuneiform so that some mobility
can be maintained between the medial and
lateral aspects of the longitudinal arch. Not
fusing the cuboid to the lateral cuneiform
appears to give the foot a little more flexibility
to adapt to the ground.
Indications
The main indication for arthrodesis of the tarsometatarsal joints is arthrosis resulting in pain,
deformity, or both. The arthrodesis can include
a single joint or multiple joints.
Position of Arthrodesis
The arthrodesis site is positioned to correct any
forefoot abduction or adduction or dorsiflexion.
At times a complex deformity from trauma, particularly a crush injury, results in a deformity
involving multiple planes, and it can be difficult
to achieve a plantigrade foot. However, the
surgeon should attempt to obtain a foot as close
to plantigrade as possible.
Surgical Technique
1. The patient is placed in a supine position,
and a tourniquet is used about the thigh
(video clip 13).
2. The surgical approach varies, depending on
which joints are being arthrodesed. For an
isolated first tarsometatarsal arthrodesis, a
dorsomedial incision is used, centered over
the joint. This allows satisfactory visualization of the joint as well as access to the
dorsum of the foot to insert screws for internal fixation.
3. For an isolated second MTC arthrodesis, the
incision is made just lateral to the midportion of the joint. By placing the incision
here, the neurovascular bundle is located
medial to the incision. Subperiosteal dissection can safely mobilize and retract the
neurovascular bundle medially.
4. The approach to the first, second, and third
tarsometatarsal joints is carried out through
two longitudinal incisions. The first is centered over the dorsomedial aspect of the
first tarsometatarsal joint or possibly slightly
toward the midline, compared with the isolated fusion. The second incision is made

1116

PART V

Arthritis, Postural Disorders, and Tendon Disorders

Figure 209 A, Lateral incision used to expose lateral Lisfrancs joint. B, Postoperative photograph demonstrating dorsal and
dorsal-medial incision.

5.

6.

7.

8.

9.

just to the lateral side of the second MTC


joint. If the dorsal incision is not made
lateral enough, it is very difficult to visualize
the third MTC joint. It is important to make
long incisions to minimize traction on the
skin edges (Fig. 209).
The approach to the fourth and fifth
metatarsocuboid articulations is through a
dorsal incision centered between them,
which provides adequate exposure.
When carrying out the surgical approach to
the tarsometatarsal joints, the surgeon must
be extremely cautious, looking for the
superficial branches of the peroneal nerve
that pass along the dorsum of the foot.
Along the medial aspect of the foot, the
surgeon is usually working in an internervous interval, although occasionally the
internal division of the superficial peroneal
nerve may be encountered.
The approach to the second MTC joint is
the most hazardous, because the internal
and external divisions of the superficial peroneal nerve lie in the subcutaneous tissue in
a somewhat irregular pattern. As one proceeds deeper, the neurovascular bundle
containing the superficial branch of the
deep peroneal nerve and dorsalis pedis
artery are encountered as they pass distally.
The incision over the fourth and fifth
metatarsocuboid articulations tends to be in
an internervous interval between the external division of the superficial peroneal nerve
medially and the sural nerve laterally. Again,
however, the nerve pattern varies greatly in
this area, and nerve branches should be
carefully identified and retracted.
When approaching tarsometatarsal joints
one, two, and three, it is easier to start the

subperiosteal dissection through the medial


incision. From this incision the surgeon
identifies the skeletal plane and, with a
sharp elevator, moves along this plane,
stripping the soft tissues from the bone as
far as the third MTC joint. This usually allows
the surgeon to pass underneath the neurovascular bundle without causing damage
to it. If the foot is severely distorted,
however, this might not be safe, and the
neurovascular bundle should be identified
through the incision over the second MTC
and carefully dissected off of the bone.
10. Once exposed, the involved joints are
meticulously debrided with a curet, small
osteotome, or rongeur. All the soft tissue
and articular cartilage around the joints are
removed, including the plantar aspects.
11. Once the joints are totally mobilized, it is
always impressive how readily a deformity
can be reduced. Occasionally, usually in the
patient after trauma, some bone needs to
be removed to create congruent surfaces
for the fusion to occur.
12. After the joint surfaces have been debrided,
the foot is realigned by first placing the first
MTC joint into a plantigrade position. To
help assess alignment (in particular abduction/adduction), the surgeon should always
observe the normal foot before the procedure and relate it either to the alignment of
the patella or to the medial side of the talus
and hindfoot. As a general rule, when a
deformity is present at the first MTC joint, it
is usually abduction and dorsiflexion. Therefore, the first metatarsal is usually manipulated into some adduction and plantar
flexion. If the alignment appears correct and
good bone apposition is present, the bone

CHAPTER 20

13.
14.

15.
16.

ends are feathered and the anticipated


fusion site stabilized with the guide pin from
the 4.0-mm cannulated screw set. If the
apposition is not satisfactory, some bone is
removed, feathered, and pinned.
The alignment is carefully checked again,
and if it is satisfactory, internal fixation can
be inserted.
Once the first MTC joint is aligned and stabilized, the other metatarsal bases are
brought over to it, which effectively realigns
the deformity. The second metatarsal is
adducted so that it comes to lie next to the
first and then is slightly plantar flexed. As
the metatarsal is plantar flexed, the surgeon
palpates the first metatarsal head to be sure
that the degree of plantar flexion of the
second metatarsal head is not excessive.
The cuneiforms usually are not very
deformed and tend to fall into place as the
metatarsals are manipulated into a plantigrade position.
If the third MTC joint is to be arthrodesed,
it is aligned next in relation to the second,
and in this way the deformity is corrected.
When the fourth and fifth MTC joints are
involved, as mentioned previously, an

A1

Arthrodesis of the Foot and Ankle

1117

attempt is made to carry out the fusion only


to the cuboid. The surgeon must be careful not to fuse the third cuneiformcuboid
articulation.
17. The internal fixation can be carried out in
many ways, but we prefer to use the 4.0-mm
cannulated screw with a small head.
Because the skin is thin in this area, the lowprofile heads can usually be buried, so they
do not require removal.
18. The first MTC joint is fixed by inserting one
screw from the dorsal aspect of the first
metatarsal into the medial cuneiform, after
which a second screw is placed from the
dorsal aspect of the medial cuneiform into
the base of the first metatarsal. This gives
rather rigid internal fixation to the joint.
As the screws are inserted, the joint surfaces are compressed with a towel clip
(Fig. 2010).
19. The second MTC joint is fixed by placing a
long oblique screw, starting in the metatarsal and passing it proximally across
the joint into the cuneiform. The angle that
this pin makes with the second metatarsal is
extremely acute and at times is difficult to
start because the guide pin tends to slide

A2

B1

B2

Figure 2010 Tarsometatarsal arthrodesis. A, Preoperative and postoperative radiographs demonstrate arthrodesis of the first
metatarsocuneiform (MTC) joint using two 4.0-mm cannulated screws. This method gives excellent internal fixation. Note the
subtalar fusion as well. B, Preoperative and postoperative radiographs demonstrate arthrodesis at the first MTC joint with two
crossed screws. Note that the deformity has been significantly improved, although not totally corrected, by the arthrodesis.

1118

PART V

Arthritis, Postural Disorders, and Tendon Disorders

along the metatarsal proximally. This can


sometimes be overcome by making a small
vertical drill hole to identify where to start
the guide pin, which is usually about 2 cm
distal to the joint. The guide pin usually
catches on this edge of bone and does not
tend to slide up the metatarsal. If this screw
is not placed obliquely enough, it will not
engage the cuneiform adequately, and rigid
fixation will not be achieved (Fig. 2011).
20. Once the guide pin is in satisfactory position, the metatarsal is drilled with the 4.0mm bit. The hole is countersunk to lower

the profile of the head and prevent the


screw head from impinging against the
metatarsal when it is seated, which can fracture the dorsal portion of the metatarsal.
21. The third MTC joint is fixed in a manner
similar to the second. Occasionally the
screw is placed from the lateral aspect of
the base of the metatarsal obliquely into the
third or occasionally the second cuneiform.
22. Once the tarsometatarsal joints have been
fixed, a screw is placed across the cuneiforms, depending on the extent of the
fusion site. If only a single articulation is

Figure 2011 Preoperative (top) and postoperative (bottom) radiographs demonstrate isolated arthrodesis (arrows) of second
metatarsocuneiform joint. (From Mann RA, Coughlin MJ: The Video Textbook of Foot and Ankle Surgery. St. Louis, Medical Video
Productions, 1991.)

CHAPTER 20

being fused, it is not necessary to fuse the


cuneiforms to one another. If the first,
second, and third MTC joints are being
fused, however, a screw is placed mediolaterally across the cuneiforms to stabilize
them. Another screw is then placed from the
medial aspect of the first metatarsal base
obliquely into the cuneiforms. This screw
may also cross the second MTC joint. This
screw helps to reinforce the fusion mass and
ensure that rigid fixation is achieved.
23. When the naviculocuneiform joints are
included in the fusion mass, a screw can be
passed from the tip of the navicular into the
cuneiforms, which usually provides excellent internal fixation. If the naviculocuneiform joints are to be included in the fusion
site, it is imperative that at least the first and

Arthrodesis of the Foot and Ankle

1119

second cuneiforms be involved because an


isolated fusion of the medial cuneiform and
the navicular is difficult to achieve. Screws
can also be placed from the cuneiforms into
the navicular (Fig. 2012).
24. Fixation of the metatarsocuboid joint is
usually achieved by placing a screw from the
dorsal aspect of the fourth metatarsal into
the cuboid. The fixation of the fifth metatarsocuboid joint is more difficult because the
actual articulating surface is quite small. An
oblique guide pin may be placed percutaneously from the lateral aspect of the
metatarsal base into the cuboid and a screw
inserted over it.
25. Proliferative bone over the dorsal aspect of
the MTC joints is removed, morselized, and
packed into any existing spaces in the

A
Figure 2012 Midfoot arthrodesis of multiple joints. A, Preoperative and postoperative radiographs of intertarsal arthrodesis
for degenerative arthrosis. Note that the screw pattern locks navicular to the cuneiforms; also note the intercuneiform screws. If
the tarsometatarsal joints are not involved, the arthrodesis does not need to include them.
Continued

1120

PART V

Arthritis, Postural Disorders, and Tendon Disorders

C1

B1

B2
C2

E1

D1

D2
E2

Figure 2012contd B and C, Preoperative (1) and postoperative (2) radiographs demonstrate arthrodesis of tarsometatarsal
joints 1, 2, and 3, along with cuneiforms using a four-screw pattern. Note the correction of deformity in both the anteroposterior and lateral planes. D and E, Preoperative (1) and postoperative (2) radiographs demonstrate arthrodesis of tarsometatarsal
joints 1, 2, and 3, along with intercuneiform joints using a six-screw pattern. The number of screws used depends on the stability of fixation needed to obtain rigid fixation. Note the correction of deformity in both the anteroposterior and lateral planes.

CHAPTER 20

fusion site. If the surgeon is not satisfied


with the apposition of the bone surfaces, a
bone graft, generally from the calcaneus or
medial malleolus, can be used.
26. The skin closure is very important in these
cases. The skin is very fragile, and when
multiple joints are arthrodesed, moderate
swelling can occur.
27. The subcutaneous tissue is closed with 3-0
plain sutures and the skin with a running
longitudinal near-far/far-near suture, which
keeps tension off the skin edges.
Postoperative Care
At the conclusion of the procedure, 0.25% bupivacaine is placed into the surgical field to
provide initial postoperative pain relief. A
compression dressing consisting of fluffs and a
heavy cotton bandage incorporating two plaster
splints is applied. In the recovery room, a
popliteal block is placed to control the initial
postoperative pain.
The patient is kept nonweight bearing in the
postoperative cast for approximately 12 to 14
days, after which the cast is removed and the
patient placed into a short-leg removable cast
with an elastic bandage to control swelling. The
patient is keep nonweight bearing for 6 weeks.
At 6 weeks radiographs are obtained, and if
early union is occurring, weight bearing is permitted in the cast for another 6 weeks. Twelve
weeks after surgery, radiographs are again
obtained, and if satisfactory union has occurred,
the patient is gradually permitted to work out of
the removable cast and into a shoe. An elastic
stocking is used to control swelling.
Complications
The three main complications that can occur
after a tarsometatarsal arthrodesis are skin
slough, nonunion, and failure to correct a
malalignment.
The skin on the dorsum of the foot often has
little subcutaneous fat. Combined with postoperative swelling and multiple incisions, this can
lead to a skin slough. Therefore, meticulous care
must be taken at surgery to obtain a good subcutaneous closure followed by a skin closure,
with a minimum amount of tension along the
skin edge. I prefer a running, horizontal mattress
suture that keeps the tension off the skin edges
as much as possible. If a slough occurs, local

Arthrodesis of the Foot and Ankle

1121

wound care usually is adequate to resolve the


problem, but sometimes a skin graft or even a
flap is necessary. If the slough is not too large,
vacuum-assisted wound closure (wound-VAC)
maybe useful.
A nonunion of an attempted fusion site can
occur, although infrequently. With meticulous
preparation of the bone surfaces and rigid internal fixation, the tarsometatarsal joints have a
high fusion rate. We were able to obtain a fusion
in 176 of 179 joints for a 98% fusion rate.41 If a
nonunion occurs and is symptomatic, the fibrous
tissue around the involved joint needs to be
excised, the bone surfaces once again scaled,
the joint bone grafted if necessary, and internal
fixation reapplied.
Malalignment of the foot can be a problem.
The deformity usually present preoperatively is
abduction and dorsiflexion, which results in a
large prominence on the plantarmedial aspect
of the foot in the area of the first tarsometatarsal
joint. If the forefoot is not reduced by bringing
the first metatarsal into adduction and plantar
flexion, this prominence remains and might continue to be a source of pain for the patient. With
adequate reduction, this prominence does not
strike the ground, which usually provides relief
for the patient. Occasionally, malalignment of a
metatarsal occurs by placing it into too much
dorsiflexion or plantar flexion, which can be corrected with an osteotomy and internal fixation if
necessary.
A neuroma, particularly on the dorsum of the
foot, can also occur from entrapment or laceration of one of the sensory nerves on the dorsum.
Usually a small branch is involved, and although
annoying to the patient, it usually is not a major
problem. Occasionally, if one of the larger
branches of a superficial peroneal nerve is cut,
a large, painful neuroma develops and is aggravated by footwear. If this occurs and is symptomatic, the neuroma should be identified and
buried either underneath the extensor digitorum brevis muscle or into a hole in the bone.
The dorsum of the foot being so devoid of fatty
tissue in some patients sometimes makes it difficult to bury the nerves cut end adequately.
Authors Experience
We reviewed a series of 40 patients (41 feet)
who underwent surgery, with a follow-up of 6
years (range, 2 to 17).41 The diagnoses were
primary arthrosis in 21 patients (18 women, 3

1122

PART V

Arthritis, Postural Disorders, and Tendon Disorders

men) and 22 feet, post-trauma effects in 17 (9


women, 8 men), and inflammatory arthritis in
two (one man, one woman). The age for the
primary arthrosis group was 60 years (range, 27
to 75), for post-trauma group 40 years (range,
30 to 67), and for arthritis group 44 and 70
years. The patients noted symptoms for an
average 2.8 years for the post-trauma group,
10.9 years for the primary arthrosis group, and
14 years for the arthritis group.
Preoperatively, all the patients complained of
pain, and 78% had a foot deformity that made
wearing shoes difficult. The group with primary
arthrosis had a greater degree of deformity than
the patients with traumatic arthrosis.
Using the technique described previously, we
were able to obtain union in 176 of 179 joints
for a 98% union rate. Of the three nonunions
that occurred, one required surgical repair.
Patient satisfaction was 93% (38 of 41 feet).
Postoperatively, five patients had a prominent
metatarsal head, although none developed a
callus that required trimming. The prominent
head involved the second metatarsal twice,
second and third metatarsals twice, and first and
second metatarsals once. Three patients developed a stress fracture of the second metatarsal,
and all of them healed spontaneously. Three
feet demonstrated minimal neuritic symptoms
along one of the dorsal scars, but none required
further treatment.
The preoperative radiographic findings demonstrated that the patients with primary arthrosis
had more pronation than those with traumatic
arthrosis. The deformity observed in the AP
radiograph was usually two times greater
than that noted on the lateral radiograph. The
average correction obtained in the AP plane
(i.e., abduction or adduction) was 9 degrees,
which compares favorably to that of Horton and
Olney,39 who obtained a 10-degree correction.
In the lateral radiograph we obtained an
average correction of 8 degrees, which was
approximately half that reported by Horton and
Olney. At follow-up, arthrosis not present preoperatively was observed in adjacent joints in
three patients (five joints) in the post-trauma
group and eight patients (12 joints) in the
primary arthrosis group. None of these were
symptomatic.
Our failure rate of the procedure was 3 (7%)
of 41, which was lower than that reported by
Sangeorzan et al,42 whose failure rate was 5

(31%) of 16, and Johnson et al,40 whose rate was


2 (15%) of 13.
The primary differences between patients
with primary arthrosis and post-trauma arthrosis
were age (60 versus 41 years, respectively) and
the extent of the deformity, which was greater
in the primary arthrosis patients. These patients
had an average of six joints fused per foot,
whereas the post-trauma patients had four joints
per foot.
After surgery, one patient continued to use an
AFO, and 11 used some type of an orthotic
device (e.g., Hapad, Spenco liner) in their shoe.
No patient required custom-made footwear.

REFERENCES
Subtalar Arthrodesis
1. Angus PD, Cowell HR: Triple arthrodesis: A long-term review. J
Bone Joint Surg Br 68:260-265, 1986.
2. Bennett GL, Graham CE, Mauldin DM: Triple arthrodesis in
adults. Foot Ankle 12(3):138-143, 1991.
3. Graves SC, Mann RA, Graves KO: Triple arthrodesis in older
adults. J Bone Joint Surg Am 75:355-362, 1993.
4. Haritidis JH, Kirkos JM, Provellegios SM, Zachos AD: Long-term
results of triple arthrodesis: 42 cases followed for 25 years. Foot
Ankle 15(10):548-551, 1994.
5. Kitaoka HB, Alexander IJ, Adelaar RS, et al: Clinical rating
systems for the anklehindfoot, midfoot, hallux and lesser toes.
Foot Ankle 15(7):349-353, 1994.
6. Haskell A, Pfeiff C, Mann R: Subtalar joint arthrodesis using a
single lag screw. Foot Ankle Int 25:774-777, 2004.
7. Mann RA, Baumgarten M: Subtalar fusion for isolated subtalar
disorders: Preliminary report. Clin Orthop Relat Res 226:260265, 1988.
8. Mann RA, Beaman DN, Horton G: Isolated subtalar arthrodesis. Foot Ankle Int 19(8):511-519, 1998.
9. Russotti GM, Cass JR, Johnson KA: Isolated talocalcaneal
arthrodesis: A technique using moldable bone graft. J Bone Joint
Surg Am 70:1472-1478, 1988.
10. Sangeorzan BJ, Smith D, Veith R, Hansen ST: Triple arthrodesis
using internal fixation in treatment of adult foot disorders. Clin
Orthop Relat Res 294:299-307, 1993.
11. Southwell RB, Sherman FC: Triple arthrodesis: A longterm study with force plate analysis. Foot Ankle 2(1):15-24,
1981.
12. Stephens HM, Sanders R: Calcaneal malunions: Results of a
prognostic computed tomography classification system. Foot
Ankle Int 7(7):395-401, 1996.
13. Swiontkowski MF, Scranton PE, Hansen S: Tarsal coalitions:
Long-term results of surgical treatment. J Pediatr Orthop 3:287292, 1983.
14. Tenuta J, Shelton YA, Miller F: Longer-term follow-up of triple
arthrodesis in patients with cerebral palsy. J Pediatr Orthop
13:713-716, 1993.
15. Wetmore RS, Drennan JC: Long-term results of triple arthrodesis in CharcotMarieTooth disease. J Bone Joint Surg Am 71:417422, 1989.

CHAPTER 20

16. Wukich OK, Bowen RJ: A long-term study of triple arthrodesis


for correction of pes cavovarus in CharcotMarieTooth disease.
J Pediatr Orthop 9:433-437, 1989.
Talonavicular Arthrodesis
17. Clain MR, Baxter DE: Simultaneous calcanealcuboid and
talonavicular fusion: Long-term follow-up study. J Bone Joint
Surg Br 76:133-136, 1994.
18. Elbaor JE, Thomas WH, Weinfeld NS, Potter TA: Talonavicular
arthrodesis for rheumatoid arthritis of the hindfoot. Orthop Clin
North Am 7:821-826, 1976.
19. Elftman H: The transverse tarsal joint and its control. Clin
Orthop Relat Res 16:41, 1960.
20. Fogel GR, Kato HY, Rand JA, Chao EY: Talonavicular arthrodesis for isolated arthrosis: 9.5 year results and gait analysis. Foot
Ankle 3(2):105-113, 1982.
21. Harper MC, Tisdel CL: Talonavicular arthrodesis for the painful
acquired flatfoot. Foot Ankle Int 17(11):658-661, 1996.
22. OMalley MJ, Deland JT, Lee K: Selective hindfoot arthrodesis
for the treatment of adult acquired flatfoot deformity: An in
vitro study. Foot Ankle Int 16(7):411-417, 1995.
Double Arthrodesis
23. DuVries HL: Surgery of the Foot. St Louis, Mosby, 1959, p 300.
24. Inman VT (ed): DuVries Surgery of the Foot, ed 3. St Louis,
Mosby, 1973, pp 491-494.
25. Mann RA, Beaman DN: Double arthrodesis for posterior tibial
tendon dysfunction. Clin Orthop Relat Res 365:74-80, 1999.
Triple Arthrodesis
26. Adelaar RS, Dannelly EA, Meunier PA, et al: A long-term study
in triple arthrodesis in children. Orthop Clin North Am 7:895908, 1976.
27. Angus PD, Cowell HR: Triple arthrodesis: A critical long-term
review. J Bone Joint Surg Br 62:260-265, 1986.
28. Bennett GL, Graham CE, Mauldin DM: Triple arthrodesis in
adults. Foot Ankle 12(3):138-143, 1991.
29. Drew AJ: The late results of arthrodesis of the foot. J Bone Joint
Surg Br 33:496-502, 1951.

Arthrodesis of the Foot and Ankle

1123

30. Graves SC, Mann RA, Graves KO: Triple arthrodesis in older
adults: Results after long-term follow-up. J Bone Joint Surg Am
75:355-362, 1993.
31. Haritdis JH, Kirkos JM, Provellegios SM, Zachos AD: Long-term
result of triple arthrodesis: Forty-two cases followed for twentyfive years. Foot Ankle Int 15(10):548-551, 1994.
32. Jahss MH, Godsick PA, Levin H: Quadruple arthrodesis with
iliac bone graft. In Bateman JE, Trott AW (eds): The Foot and
Ankle, New York, Thieme-Stratton, 1980, pp 93-102.
33. Lambrinudi C: New operation on drop-foot. Br J Surg 15:193200, 1927.
34. Mann RA, Mann JA, Prieskorn D, Sobel M: Posterior tibial
tendon dysfunction treated by fusion. Paper presented at
the 18th Annual Verne T. Inman Lectureship, University of
California, San Francisco, May, 1997.
35. Ryerson EW: Arthrodesing operations on the feet. J Bone Joint
Surg 5:453-471, 1923.
36. Smith RW, Shen W, DeWitt S, Reischl SF: Triple arthrodesis in
adults with non-paralytic disease. J Bone Joint Surg Am 86:27072713, 2004.
37. Southwell RB, Sherman FC: Triple arthrodesis; a long-term
study with force plate analysis. Foot Ankle 2(1):15-24, 1981.
37. Wetmore RS, Drennan JC: Long-term results of triple arthrodesis in CharcotMarieTooth disease. J Bone Joint Surg Am 71:417422, 1989.
Tarsometatarsal Arthrodesis
39. Horton GA, Olney BW: Deformity correction and arthrodesis of
the midfoot with a medial plate. Foot Ankle 14:493-499, 1993.
40. Johnson JE, Johnson KA: Dowel arthrodesis for degenerative
arthritis of the tarsometatarsal (Lisfranc) joints. Foot Ankle
6(5):243-253, 1986.
41. Mann RA, Prieskorn D, Sobel M: Mid-tarsal and tarsometatarsal arthrodeses for primary degenerative osteoarthrosis or
osteoarthrosis after trauma. J Bone Joint Surg Am 78:1376-1385,
1996.
42. Sangeorzan BJ, Veith RG, Hansen ST Jr: Salvage of Lisfrancs tarsometatarsal joint by arthrodesis. Foot Ankle 10(3):193-200,
1990.