Triple arthrodesis

History
The early hind foot arthrodeses were used to treat polio.
Davis in 1913 described fusion of the talocalcaneal and talonavicular joints as a
way of correcting varus-valgus and abduction-adduction deformities of the foot.
Ryerson proposed additionally fusing the TMT joints and the calcaneocuboid
joints. The former is no longer performed, but the latter is, to provide a triple
arthrodesis.
Indications
The indications for arthrodesis are pain, deformity and instability refractory to
nonoperative measures.
Goal is to achieve a stable, painless plantigrade foot. The operation is designed
as a salvage operation in older patients who have a painful fixed deformity
refractory to other treatment.
The most common indications include post traumatic osteoarthritis and
rheumatoid arthritis.
Preoperative evaluation
Need to ensure adequate vascular status; if pedal pulses are impalpable, need to
perform Doppler assessment of ABI and waveforms, and consider referral to a
vascular surgeon.
Need to understand relationships of hindfoot and forefoot. Pes planus involves a
pronated foot, with the heel in valgus and the forefoot abducted at the
talonavicular joint and in varus. To correct this deformity the heel must be
brought out of excessive valgus to approximately 5 degrees of residual valgus;
forefoot abduction must be corrected by reduction of the talonavicular joint;
forefoot varus should be corrected to neutral by derotation of the metatarsals.
Patients with long standing pes planus will often have contracture of the gastrocsoleus complex. To assess this the talonavicular joint should be reduced to
neutral prior to attempted dorsiflexion of the ankle.

In pes cavus the heel is in varus and the forefoot is adducted and in valgus.
Imaging
Full weight bearing plain XRs of the foot in the AP, lateral and oblique plains are
taken.
In the AP of the foot there will be an increase in the talocalcaneal angle (Kites
angle) in pes planus, and a decrease in pes cavus.
An AP ankle should also be taken. Valgus angulation of the talus in the ankle
mortise is suggestive of deltoid ligament insufficiency.
Surgical technique (after Mann)
Two incision technique.
1.

2.

3.

Lateral incision provides exposure of the subtalar and calcaneocuboid

joints.
a. The incision runs from the tip of the fibula towards the base of the
fourth MT
b. This is an internervous plane between the sural nerve and the
intermediate branch of the superficial peroneal nerve.
i. Be aware of a communicating branch between the two nerves
seen in 40%
c. The incision is deepened and the inferior border of EDB identified.
The muscle is reflected superiorly to gain access to the subtalar joint.
The fat in the sinus tarsi is also reflected superiorly
d. The interosseous ligament is divided
e. A laminar spreader is placed into the joint and the posterior, middle
and anterior facets debrided of cartilage, feathered with an osteotome
and drilled with a K-wire
f. The calcaneocuboid joint is then opened up and debrided.
Medial incision
a. Made dorsomedially from the tip of the medial malleolus to the level
of the naviculo-cuneiform joint. An interval is created between tibialis
anterior and tibialis posterior
b. The joint is exposed via subperiosteal exposure of the dorsum of the
navicular, trying not to strip off the periosteum from the talar neck to
avoid AVN
Fixation
2

4.
5.

a. The subtalar joint is stabilized first. The heel should be in 5 degrees of

valgus. Note that the order of fusion is controversial; Myerson says
that the talonavicular joint should be reduced first, and this will reduce
the subtalar joint passively. However, if the subtalar joint is reduced
first, movement (and hence reduction) of the talonavicular joint is
possible, but if the talonavicular joint is fixed first the subtalar joint
isnt moveable.
b. The subtalar joint is fixed in 5 degrees of valgus. Too much valgus will
cause fibular impingement and increased stress on the medial
collateral ligament of the knee.
c. Cannulated screws are used, running from the postero-inferior aspect
of the calcaneus to the neck of the talus. While drilling an ACL drill
guide may be useful.
d. If there has been significant bone loss then addition of graft should be
used instead of further bone resection
e. The forefoot is then corrected and screws placed across the
talonavicular joints and calcaneocuboid joints. Myerson emphasizes
that the cuboid should be forcibly elevated while it is fixed to prevent
excessive pressure along the lateral column. He also emphasizes that
the recess between the navicular and the cuboid, where the navicular,
cuboid, talus and calcaneus are all very close together and may be
touching, needs to be opened up and perhaps grafted; if this is done
the triple arthrodesis may be stable even if there is radiological
evidence of nonunion at one of the joints. Jahss calls this concept the
quadruple arthrodesis.
f. If the calcaneus is still impinging on the fibula it may be necessary to
do a medializing calcaneal osteotomy.
g. Provisional K-wires should be placed first and the position checked on
XR
Check status of tendo Achilles if tight perform tendo Achilles release
Postoperative
a. Place in compressive dressing and backslab
b. Full cast non weight bearing for 6 weeks
c. Walking cast for further 6 weeks

Complications
1.
Malalignment

2.

3.

4.
5.

a. Excessive hind foot valgus leads to stress on the deltoid ligament and
secondary increased forces across the ankle with increased risk of
ankle OA
b. Excessive hind foot valgus can also lead to subfibular impingement
and late degeneration of the medial collateral ligament of the knee.
c. Residual hind foot varus will lead to overloading of the lateral column
of the foot with resultant pain in the 5 th MT and cuboid. Persistent
forefoot supination is treated with a derotational midtarsal osteotomy.
d. Malalignment may require revision which can be via Dwyer type
osteotomy
Nerve injury
a. Neuroma formation of the sural nerve or intermediate branch of
superficial peroneal nerve
Degenerative arthritis of other joints
a. Radiographic changes in the TMT and ankle have been reported in
more than 50% of patients but these are often not clinically significant
AVN of the talus
Nonunion most commonly affects talonavicular joint (up to 33%)
a. If asymptomatic, no revision is required; if symptomatic redo with
grafting

Postoperative course
It may take some time for symptoms to settle, ranging from 2 up to 36 months;
the patient should be informed of this.
Other arthrodeses
Talonavicular fusion severely restricts transverse tarsal and subtalar motion. An
isolated talonavicular arthrodesis may be performed in sedentary patients. If the
patient is active this should be combined with a calcaneocuboid arthrodesis to
increase the chance of successful fusion. This will have the same functional effect
as a triple arthrodesis.
An isolated calcaneocuboid arthrodesis doesnt substantially affect subtalar
motion, preserving around 70% of residual hindfoot motion.
This is the basis of its use for lateral column lengthening in pes planus.