23 Triple Arthrodesis Abstract The triple arthrodesis includes fusion of the subtalar, talonavicular, and calcaneocuboid joints to address hindfoot deformity and arthritis. It is crucial to fuse the joints in an anatomic alignment to rebalance the tripod effect of the foot and prevent deformity and pain at adjacent joints, particularly the ankle joint. In many cases, the calcaneocuboid joint can be spared from inclusion in the fusion (double arthrodesis) obtaining similar correctability of the deformity while maintaining more flexibility of the lateral column of the foot. This chapter outlines the indication, advantages, and the surgical technique focusing on the tricks to obtaining the most optimal outcome. Keywords: triple, double, pes planovalgus, hindfoot arthritis • Degenerative flatfoot (stage 3 adult acquired flatfoot). • Posttraumatic hindfoot disease. • Rheumatoid/autoimmune hindfoot disease. • Charcot’s hindfoot dislocation. • Spastic hindfoot instability. • Stiff hindfoot in gait and manual testing. • Tender and painful in sinus tarsi, subfibular area, and transverse tarsal joints. • Varus/valgus collapse on standing exam. • Most often tight Achilles complex. • Flatfoot series (standing anteroposterior [AP]/lateral of both feet, standing AP/mortise of both ankles; Fig. 23.1a,b). • Axial alignment view. • Computed tomographic (CT) scan if concerned about the involvement of the calcaneal cuboid joint and bone stock for the fusion. • Magnetic resonance imaging (MRI) if concerned with talar or navicular vascularity. • MRI to confirm degenerative changes in flatfoot deformity unclear on radiographs. • Fluoroscopically directed selective injections can be helpful to only fuse the joints that are causing the pain. • Brace (soft hindfoot ankle brace up to a rigid ankle–foot orthosis [AFO] or an Arizona brace). • Repetitive injections. • Active infection. • Dysvascular limb. • Realignment of the hindfoot in relation to the rest of the lower extremity. • Realign the forefoot to the hindfoot (correct residual forefoot varus and valgus). • Fuse affected/painful joints. • Creation of a stable plantar grade hindfoot. • Realigns the foot under the ankle. • Can address massive deformities. Fig. 23.1 (a) Standing anteroposterior view of the foot. Valgus collapse shows the lateral peritalar subluxation of the talonavicular (TN) joint. (b) Standing lateral view of the foot shows collapse at the TN joint. • Reliable and reproducible results. • Disadvantages: We have evolved to more double arthrodesis (subtalar [ST] and talonavicular [TN] joints) and then true triples (including the calcaneocuboid [CC] joint) in the last 10 years. The reasoning is that we are only fusing the joints that need to be fused. This ends up being less surgery for the patients. The troublesome healing of the lateral incision becomes less of an issue with large corrections from planovalgus deformities. In addition, the lateral column maintains more flexibility if the CC joint is left alone. If the CC joint is symptomatic preoperatively, it can be addressed without changing the approach. We have also trended away from the “medial double” (fusing TN and ST through and extensile medial approach). Concern with the deltoid release required with this approach resulting in some cases of talar AVN (avascular necrosis) and valgus collapse has tempered our enthusiasm for the all medial approach. • Soft-tissue contracture releases. • Exposure and removal of blocking bony prominences. • Removal of chondral surfaces of joints to fuse. • Preparation of those joints. • Graft defects. • Correct all deformities. • Rigid compressive fixation. • Radiographic confirmation. • Layered closure. • Place sandbag under operative hip. The tibial tubercle should point to the ceiling. This allows access to the lateral foot. If the limb is externally rotated, a larger bump or wedge may have to be used. • Prep and expose the limb to the knee. This helps with alignment and gives access to the proximal tibia for bone graft. The type of deformity determines the releases necessary. The Achilles tendon (AT) tends to be consistently tight in varus and valgus as well as neutral degenerative cases. In hindfoot fusions, we recommend an AT lengthening rather than a gastrocnemius recession. Make incisions over the center of the AT. Make the three incisions: (1) distal just above the insertion, (2) proximal just distal to the musculotendinous junction of the muscle and the tendon, and (3) the middle equidistance from the distal and proximal (Fig. 23.2). Use a no. 15 blade. Cut through the AT in line with the fibers, turn the blade in the direction you want to cut, and finish the hemisection with a move toward the skin. The ankle should be held in maximum dorsiflexion to tension the AT while doing the hemisections. If the deformity is valgus, the cuts should be made lateral, medial, then lateral (distal to proximal), and if it is varus or neutral, the cuts should be made medial, lateral, and then medial. If the hemisections are complete and dorsiflexion tension is adequate, there will be a give and the dorsiflexion in the ankle will be restored. The posterior tibialis (PT) tendon is tight in varus and can be released through the TN approach. The peroneus brevis (PB) tendon is often tight in valgus and can be released or lengthened through the lateral incision.
23.1 Indications
23.1.1 Clinical Evaluation
23.1.2 Radiographic Evaluation
23.1.3 Nonoperative Options
23.1.4 Contraindications
23.2 Goals of Surgical Procedure
23.3 Advantages of Surgical Procedure
The patient loses the ability for foot to accommodate uneven surfaces.
Stress on the joints adjacent to the fusion (ankle and navicular cuneiform most common) can result in degeneration in those joints.
Potential for nonunion.
23.3.1 Triple versus Double Arthrodesis
23.4 Key Principles
23.5 Preoperative Preparation and Patient Positioning
23.6 Operative Technique
23.6.1 Soft-Tissue Contracture Release
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