Triple Arthrodesis: A Fully Percutaneous Approach



Triple Arthrodesis: A Fully Percutaneous Approach


Ettore Vulcano



♦ PREPARATION


Room Setup

The author routinely places the patient supine with the surgical foot at the edge of the table with a bump under the ipsilateral hip so as for the ankle to be facing “straight up.” The contralateral leg is frog-legged to avoid interference with the mini C-arm and/or the operator. The power box and the scrub technician are always at the left side of the patient, whereas the mini C-arm is always at the right side of the patient, regardless of surgical site laterality (Figure 20.1). The power box should be set at 6,000 rpm. The use of a tourniquet is highly discouraged as the intraosseous bleeding may help cool down the burr during the procedure, thus reducing the risk of heat necrosis.

Saline irrigation of the burr throughout the procedure is also crucial to reduce the risk of thermal injury to the soft tissues. This may be in the form of automated irrigation systems provided by several manufacturers distributing minimally invasive surgery instrumentation or manually by the surgical assistant with the use of a bulb syringe.








SURGICAL TECHNIQUE

The surgeon will stand at the end of the bed and may move to the side of the patient as needed. A bump under the ipsilateral hip is recommended to internally rotate the foot, facilitating access to the subtalar and calcaneocuboid joints. By the time the talonavicular joint is addressed, the surgeon may opt to remove the bump as needed.


Subtalar Joint Approach

The author has transitioned from using a dual-portal approach (posterolateral and sinus tarsi) to a single-portal approach (posterolateral) as no technical advantage was perceived and to avoid injuring the sinus tarsi artery. Under fluoroscopic guidance, the posterolateral aspect of the subtalar joint is identified and a 3-mm incision is made between just posterior to the peroneal tendons. The subcutaneous tissues are dissected bluntly with a mosquito clamp. A freer elevator is advanced into the joint to “get a feel” of the joint anatomy and orientation (Figure 20.2).

Next, under fluoroscopy, the 3 × 30 cutting burr is advanced into the joint and débridement is begun (Figure 20.3). The author prefers to work from distal to proximal, tackling the talar surface first and the calcaneal cartilage next. After the débridement is completed, the joint surfaces are palpated with a curette to feel for any remaining areas of cartilage that can be removed with the curette itself (Figure 20.4). Next, a small bone rasp and a pituitary rongeur are used to remove debris from the joint and to further assist with cartilage débridement (Figure 20.5). Prior to preparing the joint with a 2-mm wire (Figure 20.6), the joint is flushed copiously with a 50-mL syringe and an 18-gauge blunt needle.