Triple Arthrodesis

By Kelvin A. Barry, Sr., DPM, BS

Introduction
Triple Arthrodesis is the fusion of the subtalar, talonavicular, and calcaneocuboid joints. It is done to:  stabilize the foot and ankle  relieve pain  correct deformity This ultimately improves function during gait.

Indications
Valgus foot deformities
pes planovalgus ruptured tibialias posterior tendon tarsal coalition and arthritic deformities

Varus foot deformities
cavus foot/ cavovarus foot talipes equinovarus

Other
lateral ankle instability neuromuscular diseases (i.e. paralytic deformities and charco joint deformities)

Procedures
Ryerson: Hoke:
This is the classic triple arthrodesis. It consists of simple joint resection. Involves the use of the head and neck of the talus as a bone graft.

This is the most effective in dealing with a drop foot provided adequate musculature is available for concurrent transfer. When the foot attempts to plantarflex, the posterior process of the talus serves as a stop against the posterior tibial malleolus.

Lambrinudi:

Brewster:

This is a countersinking operation of the talus.

Dunn Modification: Involves removal of the navicular. Seiffer or beak triple arthrodesis
The position of the arthrodesis is critical because once an arthrodesis has been achieved, the foot is in a fixed position and cannot accommodate the ground. It is essential that hindfoot is placed in about 5° of valgus, the transverse tarsal joint in 0° to 5° of abduction, and the forefoot in less than 10° of varus. If accurate alignment is not achieved, the patient will have a non-plantigrade foot, which amy result in chronic pain that may erquire a revision.

Surgical Approaches
A combination of lateral and dorsal approaches can be used for triple arthrodesis. Lateral approach allows access to the subtalar and calcaneocuboid joints. Dorsal approach allows access to talonavicular joint.

A combination of lateral and medial approach, or an oblique incision beginning 1cm posterior and distal to the tip of the lateral malleolus and extending anteriorly and distally to the level of the middle cuneiform.

Lateral Approach
1. Outline with a marking pen the anatomic borders of the distal fibula, base of the 5th metatarsal, and base of the 4th metatarsal. Draw a line from the distal tip of the fibula to the base of the 4th metatarsal. 2. Make an incision just through the outer layer of skin. Incision should run longitudinally between the course of the intermediate dorsal cutaneous and sural nerve. 3. Complete incision with a series of short, shallow strokes of the knife to avoid cutting branches of sural nerve. 4. Evacuate contents of sinus tarsi using #15 blade or ronguer. Sharply release most proximal portion of the extensor digitorum brevis from its attachment to the lateral aspect of the calcaneous and retract it distally using a senn retractor. 5. Place a freer-elevator into the subtalar joint to confirm location and orientation. 6. Place a laminar spreader in the anterior most position of subtalar joint or within the sinus tarsi to further enhance exposure of the joint. 7. To avoind thermal necrosis associated with burrs or other power tools, use small curette to completely remove cartilage from the superior and inferior surfaces of the posterior facet. Remove cartilage from the calcaneocuboid joint. 8. Use a 0.45mm or 0.62mm K-wire to drill multiple holes I floor and roof of the posterior facet to promote bleeding across these surfaces 9. Use a straight or curved osteotome to shingle or feather the surfaces

Dorsal Approach
1. Outline location of talotibial joint, the dorsalis pedis pulse, the medial prominence of navicular, and the tibialis anterior tendon. 2. Line of incision is drawn lateral to tibialis anterior. 3. Make an incision through outer layer of skin. Complete incision with small strokes to avoid injury to the neurovascular bundles. Deepen incision to the level of the extensor retinaculum and incise it sharply in line with the incision. 4. Retract tendons of tibialis anterior, extensor hallucis longus and the long toe extensors medially or laterally. 5. Carefully disesct and cauterize numerous blood vessels within the layer of fat proximal to talar neck 6. Identify talonavicular joint by placing a #15 blade or freer into the joint 7. Visualize talonavicular joint by plantarflexion of the forefoot and by opening the joint with a narrow osteotome or key elevator. 8. Remove cartilage using a small curette 9. Use a stout k-wire or small drill bit to perforate the subchondral bone 10. Use a small, straight or curved osteotome with a mallet to shingle the bone surface.

Correction of Deformities
Triple arthrodesis permits correction of foot deformities in all three planes lowers or increases the arch in the sagittal plane. For correction of a high arch foot, an increased amount of bone is resected from the oposing surfaces at the dorsal aspect of the midtarsal joint to lower the arch. Sliding of calcaneus anteriorly on the talus will dorsiflex forefoot and decrease the arch A low arched foot could be corrected by resecting more bone plantarly from the midtarsal to recreate an arch. In the transverse plane, it can correct for an adducted or abducted forefoot. For correction of adducted forefoot, do a resection of a laterally based wedge in both the talonavicular and calcaneocuboid joints to abduct the forefoot on the rearfoot. To correct an abducted forefoot, da ao resection of medically based wedge in both talonaviculer and calcaneocuboid joints. Triple arthrodesis also corrects for valgus and varus deformities in the frontal plane. For varus deformity, resect slightly more bone from lateral side of STJ and shift calcaneus slightly laterally beneath the talus. For valgus deformity, do a medially based wedge resection of STJ and shift calcaneus slightly medially beneath the talus.

Internal Fixaton
After intraoperative manipulation to bring STJ into 5 degrees of valgus, the transverse tarsal joint into about 0 to 5 degrees of abduction, and the forefoot in less than 10 degrees of varus, screws or staples are used to fixate the joints STJ is fixated first. Guide oins for the large fragment cannulated screws are placed from lateral aspect of calcaneus in a distal medial direction across the posterior facet. Intraoperative radiographs confirm correct positioning. 7.0 mm screws are then placed in the standard fashion following depth gauge measurement, drilling and tapping. It is important to have screw threads entirely across the arthrodesis site in order to achieve compression. Fixation of talonavicular joint is usually accomplished with two 4.0mm cannulated. Placement of screws across these two joints may be more traumatic or require more surgical dissection than is otherwise necessary.

Closure
Distally retracted extensor digitorum brevis is repositioned proximally across area of sinus tarsi and is sutured with 2-0 chromic cat gut. Subcutaneous tissue and skin are then closed. On dorsal side, retinaculum is closed using 2-0 chromic gut. Skin is closed. Maicaine (0.25%) is instilled into incision site to achieve initial postoperative analgesia A compressive dressing is applied

Disadvantages
1. Pseudoarhrosis and nonunion 2. Recurrence of the deformity 3. Development of DJD in joints proximal or distal to the arthrodesis site 4. Avascular necrosis 5. Ankle instability 6. Alteration on overall growth when performed in children 7. Callous formation 8. Scarring 9. Chronic edema 10. Post incisional entrapment neuropathy 11. Muscle atrophy