Techniques in Foot & Ankle Surgery 6(4):237–242, 2007
j S P E C I A L F O C U S
Double-Hindfoot Arthrodesis Through a Single
Medial Approach
Jeroen De Wachter, MD, Markus Knupp, MD, and Hintermann Beat, MD
Kantonsspital Liestal
Liestal, Switzerland
| ABSTRACT
Triple arthrodesis has stood the test of time as a proce-
dure that can restore a painful and/or deformed hindfoot
into a stable and pain-free foot. Since the first triple-
arthrodesis procedures have been described, little at the
operative technique has changed. Recent studies suggest
that some significant alterations in the technique may
lead to equally good results. The technique we present
in this article is a double arthrodesis (limiting a triple ar-
throdesis to the talonavicular and the talocalcaneal joint)
using a single medial surgical approach, thus leaving the
calcaneocuboid joint free whenever possible. When per-
formed meticulously, we consider our technique as a
valuable and safe alternative to the more classic ‘‘lateral’’
and ‘‘3-joint-fusion’’ way of thinking. Future studies are
needed to support the short-term excellent results with
this new approach.
Keywords: triple arthrodesis, double arthrodesis, medial
approach, joint fusion, hindfoot, deformity
| HISTORICAL PERSPECTIVE
The simultaneous fusion of the subtalar, talonavicular,
and calcaneocuboid joints of the footVgenerally referred
to as triple arthrodesisVhas been performed since the
beginning of the 20th century. 1 Initially mainly per-
formed as a solution for paralytic foot malformations
(poliomyelitis, Charcot-Marie-Tooth, cerebral palsy)
and for sequelae of clubfeet deformities, triple arthrode-
sis nowadays has a broader range of indications. Any ar-
thritic condition of the hindfoot with painful and/or rigid
deformity in the sagittal plane (planus-cavus), the trans-
versal plane (adductus-abductus), the coronal plane
(varus-valgus), or any combination of these can be trea-
ted with a triple arthrodesis.
Address correspondence and reprint requests to Markus Knupp, MD, 26
Rheinstrasse, 4410 Liestal, Switzerland. E-mail: Markus.Knupp@
KSLI.CH.
No support has been obtained for the work in this article.
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Ó 2007 Lippincott Williams & Wilkins, Philadelphia
j
Historically, a triple arthrodesis includes the subtalar,
the talonavicular, and the calcaneocuboid joints. Al-
though many studies show good to excellent long-term
results with respect to maintaining a corrected foot posi-
tion and subsequent pain relief,2,3 other studies have
pointed out that over time, the (nonfused) adjacent joints
to the triple arthrodesis (ie, ankle and midfoot joints)
show increased secondary arthritic degeneration.4 Con-
cern about this long-term complication has led to the
concept of limiting a triple arthrodesis to the subtalar
and talonavicular joints, and leaving the calcaneocuboid
joint free.5 Because the latter moves a few degrees dur-
ing ambulation and is often relatively well spared from
arthritic changes, reasonable belief exists that it may
act as a ‘‘force-dissipating’’ factor during ambulation.6,7
Indeed, recent studies show equally good results after
this double arthrodesis (talonavicular and subtalar joints)
when compared with the classic triple arthrodesis.8,9
A last point of interest is the surgical approach to a
triple arthrodesis. Both a single lateral approach, a com-
bined lateral and medial approach, and, recently, a single
medial approach have been proposed and advocated. A
single lateral approach has several disadvantages. In se-
vere valgus feet after correction of the deformity, skin
closure can be a potentially serious problem. A second
concern with a single lateral approach is the difficulty
reaching the talonavicular joint ‘‘across’’ the foot. No
more than 38% of the talonavicular joint could be denud-
ed with an ‘‘across-the-foot’’ approach in a cadaveric
study.10 Obviously, a second incisionVmediallyVgives
an excellent access to the talonavicular joint with con-
sequently better joint preparation. However, in addi-
tion, a single medial approach can give more than
sufficient access to the 3 joints to be fused. Another
recent cadaveric study showed that through a single
medial approach, 91% of the subtalar and talonavicu-
lar joint surfaces and 90% of the calcaneocuboid joint
surface can be prepared.11
Based on all of the above-mentioned considerations,
we recently decided to perform our triple arthrodesis as a
double arthrodesis through a single medial approach
whenever a proper indication emerged.
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| INDICATIONS AND the lateral talometatarsal and the lateral talocalcaneal

CONTRAINDICATIONS angles. In doing so, we are able to quantify the hindfoot
and midfoot deformities that are clinically visible. We do
Numerous pathologic findings can lead to a painful and/
not routinely obtain a hindfoot Salzman view.
or malaligned hindfoot. If appropriate, conservative treat-
Rarely, a computed tomographic scan is obtained for
ment is tried first. However, when this fails, surgery
better understanding of a complex hindfoot deformity.
is the next step. The goal of hindfoot surgery is to
When avascular necrosis of the talus is suspected from
achieve a functional, plantigrade, and painless foot. A
the history and/or the radiographs, a magnetic resonance
procedure that preserves normal hindfoot motion and
imaging scan can be helpful in the preoperative evalua-
mechanics should always be considered especially in
tion. When it is unclear from the clinical examination
younger patients.
and the radiographs if the calcaneocuboid joint is suffer-
Classic indications for a triple arthrodesis include
ing from an active arthritic process, we obtain a scintigra-
arthritis of the hindfoot (rheumatoid or posttraumatic),
phy. In our institution, we have a single-photonYemission
end-stage posterior tibial tendon dysfunction, and neuro-
computed tomographic scan that provides us with very
muscular diseaseYmediated hindfoot deformities (mainly
accurate visual information about the configuration of
cavovarus).12 Unless there are severe arthritic changes
the deformity and the (pathological) bone activity in all
in the calcaneocuboid joint, we consider all indica-
of the affected bones and joints.
tions for a triple arthrodesis good indications for a
Underlying vascular and/or diabetic disease are the
double arthrodesis.
most influential comorbidities, and if necessary, a multi-
An absolute contraindication for a double arthrodesis
disciplinary workup is performed first. If considered
is an acute or chronic infection of the foot. Relative con-
necessary in neuromuscular disease cases, an electro-
traindications for a double arthrodesis through a medial
myogram is obtained before surgery.
approach are a poor vascular status of the lower leg
and skin problems at the medial side of the foot. We con-
sider the medial approach easier and safer as the (single)
| TECHNIQUE
lateral approach. Prior surgery may have made the skin The surgery is performed under general or spinal anes-
on the lateral side of the foot critical and nonflexible, thesia. Regularly, a peripheral nerve block is added.
with potentially poor healing capacity. Moreover, in se- The patient is positioned supine on the operating table,
vere valgus deformity, stretching of the lateral skin after and a tourniquet is placed around the ipsilateral thigh
valgus correction can lead to extreme wound traction and and inflated to 350 mm Hg. The leg is draped free so
subsequent wound dehiscens. that the kneecap is visible. A marking pen is used to
mark the medial malleolus, the talonavicular joint, the
| PREOPERATIVE PLANNING anterior tibial tendon and posterior tibial tendon, and
the outlines of the calcaneus and the talus.
Preoperative planning includes a detailed history taking,
Next, we make a 6-cm-long skin incision starting at
a thorough clinical examination, and review of the x-rays
the navicular toward the medial malleolus, parallel and
of the foot. The skin of the foot is evaluated for sensa-
approximately 5 mm above the posterior tibial tendon
tion, prior incisions, and global trophic status. The de-
(Fig. 1). The posterior tibial tendon sheath is opened
gree and flexibility of the hindfoot valgus or varus and
and the tendon itself inspected. If serious tendinosis
adduction or abduction at the level of the midfoot is
checked for. Muscle strength is tested for posterior tibial,
anterior tibial, and peroneal muscles. Any Achilles ten-
don shortening is noted. Local tenderness over the calca-
neocuboid joint is looked for. In varus malalignment, a
Coleman block test13 is performed to eliminate a ‘‘fore-
foot-driven’’ hindfoot varus.
Standing plain radiographs of the foot in the antero-
posterior and lateral projections and standing mortise
views of the ankle are reviewed. Prior surgery, arthritic
degeneration of the involved joints (and of the ankle
and midfoot), global bone density, and/or intraosseous
cysts are readily appreciated. On the anteroposterior
foot radiograph, we measure the talocalcaneal angle,
the talometatarsal angle, and the talonavicular joint con-
gruity. The lateral foot radiograph is used for measuring FIGURE 1. Marking the incision.

238 Techniques in Foot & Ankle Surgery

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 Special Focus: Double-Hindfoot Arthrodesis
exists, the tendon is excised. Otherwise, a partial superior
release of the distal insertion of the posterior tibial ten-
don is performed for better visualization. After locating
the talonavicular joint space, the talonavicular joint cap-
sule is incised from medial to as far as possible lateral.
A special spreader is placed dorsolaterally over the
talonavicular joint using two 2.5-mm K-wires in the na-
vicular and the talus. After opening the talonavicular
joint with the spreader, it is denuded with a chisel
and curette (Fig. 2). The spreader is removed, but the
2 K-wires are left in place.
The next step is to search along the posterior tibial
tendon for the sustentaculum tali. Using an elevator,
we free the calcaneal wall down the sustentaculum. A
third K-wire is now hammered into the base of the sus-
tentaculum, taking care that it is parallel to the one that
had been left in the talus. The spreader is now placed
over the talocalcaneal joint, with its grip toward the
heel. After the joint line of the anterior facet of the talo-
calcaneal joint, the subtalar joint is opened by cutting
its joint capsule (Fig. 3), taking great care not to severe
the anterior fibers of the deltoid ligament, which run at
the posterior edge of the anterior facet (Fig. 4). The
subtalar interosseous ligaments are cut, which allows
further spreading of the talocalcaneal joint. Next, the
anterior, middle, and posterior facets of the talus and
calcaneus are denuded with the chisel and curette,
and the joints are irrigated. Next, all the denuded artic-
ular surfaces are feathered (or drilled with a 2.0-mm
drill bit) to break the subchondral plate and get good
bleeding bone.
The spreader is removed, and, if deemed necessary,
bone grafts are inserted into the joints. We routinely
use an osteoinductive bone matrix substance, deminer-
alized bone matrix (Muskuloskeletal Transplant Corpo-
ration, Edison, NJ) to fill any gaps in the arthrodesis.
The correction maneuver of the foot deformity goes
as follows: while the foot is held in a neutral dorso-
FIGURE 2. Preparing the talonavicular joint using the
special spreader.
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FIGURE 3. Spreader at the talocalcaneal joint.
plantar position at the ankle and the heel is held in neu-
tral varus-valgus, the talonavicular joint is reduced so
that it regains its congruent relationship. The K-wires
left in the talus and the navicular can be used as ‘‘joy-
sticks’’ to enforce this reduction (Fig. 5), taking care to
keep the midfoot-forefoot complex in a pronated posi-
tion during this maneuver because a residual supination
in the forefoot is detrimental.
A mechanically strong and biomechanically sound
fixation of the corrected hindfoot is of utmost impor-
tance. At least 3 screws are necessary at the talonavicular
joint: 1 large screw from the tubercle of the navicular
into the talus and, additionally, 2 smaller converging
screws from dorsally at the navicular into the talus. The
talocalcaneal joint is fixed with 2 large screws: 1 from
the tuber of the calcaneus through the posterior facet
into the talar body, and a second one from the lateroplan-
tar side of the calcaneus into the talar head. The posi-
tion of the arthrodesis and the position of the screws
are controlled under fluoroscopy (Fig. 6). We routinely
use cannulated 6.5- and 4.0-mm ideal compression
screws (Newdeal-Integra Life Sciences, Plainsboro,
NJ). In severely osteoporotic bone, we sometimes use
FIGURE 4. Preserving the deltoid ligament (marked by
the pick-ups) is crucial.
239
 Special Focus: De Wachter et al

FIGURE 5. Using the K-wires as joysticks for easier

reduction of the talonavicular joint subluxation.

fully threaded cannulated 7.3-mm screws. Alternative

fixation methods are possible, but the basic principles
described above should be respected. A partial Achilles
tendon lengtheningVwhether it be a percutaneous triple
cut or a gastrocnemius slide procedureVhas been ex-
tremely rarely necessary in our experience. The wounds
are closed in layers, the skin with interrupted nonabsorb-
able stitches. No drain is used routinely. After a thick
compressive dressing is applied and the foot is placed
in a reusable prefab splint, the tourniquet is deflated. In
our hands, the total exsanguination time averages ap-
proximately 70 minutes.

| COMPLICATIONS
Complications of the double arthrodesis technique
through a single medial approach are rare. So far,
wound problems or infection (superficial or deep) have
not occurred. Malunion (overcorrection or undercorrec-
tion of the deformity) is a potential complication, al-
though our technique provides excellent intraoperative
feedback on whether the deformity has been corrected
to its fullest extent. Nonunion of the arthrodesis is a po-
tential complication. The good visibility and therefore
easy preparation of the talonavicular joint through the
medial incision makes a nonunion of this joint rather im-
probable. The large articular surfaces of the subtalar joint
provide a large surface for bony fusion.
Of some concern is the late secondary degenerative
arthritis of the ankle and midfoot joints after talonavicu-
lar and subtalar joint arthrodesis. Theoretically, one can
argue that by not fusing the calcaneocuboid joint, more
flexibility in the hindfoot has been preserved, potentially
leading to some sparing of the ankle andVtheoretically
even moreVthe midfoot joints. In the literature, there
is no long-term follow-up evaluation of this secondary FIGURE 6. Preoperative fluoroscopy after screw place-
arthritis in the adjacent joints after a double arthrodesis ment. A, Ankle (anteroposterior). B, Foot (anteroposterior).
as presented in this article. C, Foot (lateral).

240 Techniques in Foot & Ankle Surgery

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 Special Focus: Double-Hindfoot Arthrodesis
| POSTOPERATIVE MANAGEMENT
After 2 to 3 days, the compressive dressing and tempo-
rary splint are replaced by a removable cast (Softcast;
3M, St Paul, Minn). Care is taken that this cast supports
the correction of the foot, rather than forcing it back into
its prior malalignment. An inflatable foot pump is ap-
plied if there is substantial postoperative swelling.
When the swelling has subsided, mostly between the
6th and the 14th day postoperatively, the patients get a
below-knee cast with progressive full weight bearing
allowed. The skin stitches are removed at the 14th day
postoperatively at the earliest. From the third till the
eighth week postoperatively, the patients are kept in a
walking cast.
At 8 weeks postoperative, the cast is removed, and
full weight-bearing anteroposterior and lateral radio-
graphs of the foot and mortise views of the ankle are
obtained. If sufficient bony healing of the arthrodesis is
visible on the radiographs, no further casting is neces-
sary. When in doubt that complete bony healing has oc-
curred, casting is continued for another 4 to 6 weeks.
General measures such as the wearing of compressive
stockings and strengthening exercises of the leg are en-
couraged. If the Achilles tendon needs ongoing stretch-
ing, patients are referred to a physiotherapist.
At 4 months postoperative, final clinical and radio-
graphic evaluation takes place. If necessary because of
local problems, hardware removal is considered not ear-
lier than 6 months postoperatively.
| POSSIBLE CONCERNS, FUTURE
OF THE TECHNIQUE
Most triple arthrodeses are still performed traditionally,
that is, through a single lateral or combined lateral and
medial approach, and including a fusion of the calcaneo-
cuboid joint. Based on studies by others,8,9 we started
doing our triple arthrodesis through a single medial ap-
proach, not fusing the calcaneocuboid joint whenever
possible. More future studies are necessary to confirm
good long-term results, although the concept looks
sound and the early results look promising.
The technique presented in this article offers several
advantages. First, there is no risk for postoperative lateral
skin breakdown, which is always a serious concern in
preoperated or severe valgus feet. A second advantage
is the lower risk for damaging the posteromedial struc-
tures during the preparation of the joint surfaces. The
flexor hallucis longus is especially no longer at risk dur-
ing joint preparation. Third, when preparing the joints
from lateral, the tendency to inadvertently take away
too much bone laterally exists. Obviously, in a preexist-
| REFERENCES
ing valgus foot, this would be very undesirable because
this would accentuate the valgus deformity instead of
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correcting it. Using a medial approach makes this failure
of joint preparation highly improbable. The advantage of
not fusing the calcaneocuboid joint is not only the afore-
mentioned potentially lower secondary adjacent joint ar-
thritis but also preserving lateral column length in an
often abducted pes planovalgus. Obviously, not fusing
the calcaneocuboid joint reduces operative time and
excludes the risk of a nonunion.
A double arthrodesis through a single medial ap-
proach unconditionally requires a good 3-dimensional
insight in the hindfoot, its deformity patterns, and its
correction to be obtained. Our medial approach offers
direct visual input on the nature of the deformity and
provides immediate visual feedback on reducing the
subluxated talonavicular joint and its effect on overall
foot alignment. This is not only true for the planoval-
gus foot but also for the severe cavovarus foot. Screw
placement at the talonavicular joint can be done with
continuous visual control over the obtained reduction.
The relatively straightforward and easy release of all
tight medial structures (especially the posterior tibial
tendon) makes joint reduction and control over it
much easier compared with the single lateral approach
especially in a cavovarus foot.
The major drawback of this technique is the risk of
damaging the deltoid ligament during the preparation
of the subtalar joint. Discerning anatomical landmarks
such as the anterior facet and the sustentaculum tali is
a critical step during the procedure. Severing the (anterior
fibers of the) deltoid ligament can lead to a valgus thrust
of the ankle during ambulation, to rapid ankle valgus
deformity, and, consequently, to ankle arthrosis (partic-
ularly because a fused hindfoot makes the lever arms in
the ankle-foot complex larger than normal). Hence,
great care needs to be taken not to damage the deltoid
ligament using the medial approach. So far, this compli-
cation has not occurred in any of the clinical studies
dealing with a medial approach to triple arthrodesis.
A last concern goes about the calcaneocuboid joint.
Our personal experience with more than 300 double (sub-
talar and talonavicular) arthrodeses shows that not a single
calcaneocuboid joint had to be fused in a later stage be-
cause of secondary arthritis. Moreover, fusion of the cal-
caneocuboid joint will stiffen the lateral column of the
foot, which is already rigid in a supinated flatfoot. As
shown in other studies, fusing the calcaneocuboid joint
through a single medial approach is technically easily fea-
sible. Fusing the calcaneocuboid joint in a triple arthrode-
sis is not a contraindication for a single medial approach.
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242 Techniques in Foot & Ankle Surgery

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