Triple Arthrodesis

Dr Chirag Patel

Department of Orthopaedics

St Stephen’s Hospital

Introduction

The most effective stabilizing

procedure in the foot is triple

arthrodesis ,fusion of the subtalar,

calcaneocuboid, and talonavicular

joints.

Triple arthrodesis limits motion of the

foot and ankle to plantar flexion and

dorsiflexion.

History

Edwin Ryerson first described classical triple arthrodesis in 1923 as fusion of all three joints,he said “ the main aim of this type of operation is improvement of function of the foot.

Lambrinudi described his operation in 1927.

The goal was to create a well aligned plantigrade and stable foot that would allowe pt with paralytic or deforming condition to better function

The most common indications were to correct lower limb deformity in child resulting from polio,cerebral palsy , charcot marie tooth disease,clubfoot.

The original procedure was performed by removing large blocks of subchondralbone and correcting angular deformity by inserting or removing wedges.correctionwas maintained by cast that often required later manipulation for loss of position

Indications

to obtain stable and static realignment of the foot,

to remove deforming forces, to arrest progression of deformity, to eliminate pain, to eliminate the use of a short-leg brace

or to provide sufficient correction to allow fitting of a long-leg brace to control the knee joint, and

to obtain a more normal-appearing foot

Generally, triple arthrodesis is

reserved for severe deformity in

children 12 years old and older;

occasionally, it may be required in

children 8 to 12 years old with

progressive, uncontrollable deformity.

Indications

Post traumatic arthrits

Degenerative arthritis

Ctev

Polio

Ra

Pes cavus

Pes planovalgus deformity

Cp

Tarsal coalition

Muscular dystrophy

Charcot’s arthropathy

Contraindication

Young child less than 12 yrs because the procedure limits growth of foot,also bones are cartilagineous in nature at this age and attempt to fuse leads to avn of talus and fibrous union instead of bony union.

Relative C/I conditions are adequately corrected and maintained via bracing soft tissue procedure and tendon balancing.

Chronic smoking

Preop planing

A paper tracing can be made from a lateral radiograph of the ankle, and the components of the subtalar joint are divided into three sections: the tibiotalarand calcaneal components and another component comprising all the bones of the foot distal to the midtarsal joint.

These are reassembled with the foot in the corrected position so that the size and shape of the wedges to be removed can be measured accurately.

Talipes equinovarus

In talipes equinovarus, the enlarged

talar head lies lateral to the midline

axis of the foot and blocks

dorsiflexion. A laterally based subtalar

wedge, combined with midtarsal joint

resection, places the talar head

slightly medial to the midline axis of

the foot

Talipes calcaneocavus

In talipes calcaneocavus, the

arthrodesis should allow posterior

displacement of the foot at the

subtalar joint. After stripping of the

plantar fascia, a wedge-shaped or

cuneiform section of bone is removed

to allow correction of the cavus

deformity, and a wedge of bone is

removed from the subtalar joint to

correct the rotation of the calcaneus

Talipes equinovalgus

, the medial longitudinal arch of the foot is depressed, the talar head is enlarged and plantar flexed, and the forefoot is abducted. Raising the talar head and shifting the sustentaculum tali medially beneath the talarhead and neck restores the arch.

A medially based wedge consisting of a portion of the talar head and neck is excised . When the hindfoot valgus deformity is cor-rected, the forefoot tends to supinate; this is controlled by midtarsal joint resection with a medially based wedge. An additional medial incision may be required for resection of the talonavicular joint.

Surgical Approach

OLLIER APPROACH TO THE TARSUS

The Ollier approach is excellent for a triple arthrodesis: The three joints are exposed through a small opening without much retraction, and the wound usually heals well because the proximal flap is dissected full thickness and the skin edges are protected during retraction

1st stape is to palpate all three

joints Begin the skin incision over the dorsolateral

aspect of the talonavicular joint, extend it obliquely inferoposteriorly, and end it about 2.5 cm inferior to the lateral malleolus

Divide the inferior extensor retinaculum in the line of the skin incision

.

In the superior part of the incision, expose the long extensor tendons to the toes and retract them medially, preferably without opening their sheaths.

In the inferior part of the incision, expose the peroneal tendons and retract them inferiorly.

Divide the origin of the extensor digitorum brevis muscle, retract the muscle distally, and bring into view the sinus tarsi.

Extend the dissection to expose the subtalar, calcaneocuboid, and talonavicular joints.

Principles of classical triple

arthrodesis Three joints are exposed by above

mentioned approache follewed by joint resection and fixation.

Resections of mid tarsal joints are usually performed first as it provides increase soft tissue relaxation and further facilitates better exposure of the subtalar joints.

Care should taken to leave as much bone as possible at this joints specially in valgus deformity because lateral column length is imp for correction

Complete removal of articular cartilage

of TN joint is must , if not possible

from the classical lateral incision then

made medial incison to, because most

common complication of the triple

arthrodesis is non union of TN joints

which requires re-do triple arthrodesis

often.

Subtalar joints should be placed 4’

valgus relatives to ground

Fixations can be done by k-wire

steples or canulated screws.

Surgical sites are closed in layers with

care taken to repair the

calcaneofibular ligaments and EDB

muscle.

A lateral drain may be used to help

prevent hematoma formation specially

when the large portions of bone

resected.

LAMBRINUDI ARTHRODESIS

The Lambrinudi arthrodesis is

recommended for correction of isolated

fixed equinus deformity in patients older

than 10 years. Retained activity in the

gastrocnemius-soleus, combined with

inactive dorsiflexors and peroneals,

causes the footdrop deformity. The

posterior talus abuts the undersurface of

the tibia, and the posterior ankle joint

capsule contracts to create a fixed

equinus deformity.

. In the Lambrinudi procedure, a wedge of bone is removed from the plantar distal part of the talus so that the talus remains in complete equinus at the ankle joint while the remainder of the foot is repositioned to the desired degree of plantar flexion.

Tendon resection or transfer may be necessary to prevent varus or valgusdeformity if active muscle power remains.

The Lambrinudi arthrodesis is not recommended for a flail foot or when hip or knee instability requires a brace.

A good result depends on the strength of

the dorsal ankle ligaments. If anterior

subluxation of the talus is noted on a

weight-bearing lateral radiograph, a two-

stage pantalar arthrodesis is

recommended.

Complications of the Lambrinudi

arthrodesis include ankle instability,

residual varus or valgus deformities

caused by muscle imbalance, and

pseudarthrosis of the talonavicular joint

TECHNIQUE

With the foot and ankle in extreme plantar flexion, make a lateral radiograph and trace the film. Cut the tracing into three pieces along the outlines of the subtalar and midtarsal joints; from these pieces the exact amount of bone to be removed from the talus can be determined with accuracy before surgery.

In the tracing, the line representing the articulation of the talus with the tibia is left undisturbed but that corresponding to its plantar and distal parts is to be cut so that when the navicular and the calcaneocuboid joint are later fitted to it the foot will be in 5 to 10 degrees of equinus relative to the tibia. unless the extremity has shortened; more equinus may then be desirable.

Expose the sinus tarsi through a long, lateral curved incision.

Section the peroneal tendons by a Z-shaped cut, open the talonavicular and calcaneocuboid joints, and divide the interosseous and fibular collateral ligaments of the ankle to permit complete medial dislocation of the tarsus at the subtalar joint.

With a small power saw (more accurate than a chisel or osteotome), remove the predetermined wedge of bone from the plantar and distal parts of the neck and body of the talus. Remove the cartilage and bone from the superior surface of the calcaneus to form a plane parallel with the longitudinal axis of the foot.

Next make a V-shaped trough transversely in the inferior part of the proximal navicular and denude the calcaneocuboid joint of enough bone to correct any lateral deformity.

Firmly wedge the sharp distal margin of the remaining part of the talus into the prepared trough in the navicular and appose the calcaneusand talus. Take care to place the distal margin of the talus well medially in the trough; otherwise, the position of the foot will not be satisfactory. The talus is now locked in the ankle joint in complete equinus, and the foot cannot be further plantar flexed.

Insert smooth Kirschner wires for fixation of the talonavicular and calcaneocuboid joints.

Suture the peroneal tendons, close the wound in the routine manner, and apply a cast with the ankle in neutral or slight dorsiflexion.

POSTOPERATIVE CARE

The cast and sutures are removed at

10 to 14 days, and the position of the

foot is evaluated by radiographs. If the

position is satisfactory, a short-leg cast

is applied, but weight bearing is not

allowed for another 6 weeks, after

which a short-leg walking cast is

applied and is worn until fusion is

complete, usually at 3 months.

Triple arthrodesis for varus

deformity

Triple arthrodesis for valgus

deformity

Pes cavus

Calceneocavovarus or cavovarus

deformity mostly seen in charcot marie

tooth disease and sometimes seen in

polio and malunited fracture talus.

Can be managed by these procedure

Siffert,forster and nachami arthrodesis

Dunn arthrodesis

Hoke kite arthrodesis

Siffert,forster and nachami

arthrodesis

Wedge of bone is removed by osteotomy from midtarsal and subtalarjoints.

Superior part of talar head is retained to form “beak” ,dosral part of navicularis included in the osteotomy.

Soft tissue structure anterior to ankle joint are left undistured.

Fore foot is then displaced plantarward and navicular is locked beneth remaining part of talus head.

Dunn method of triple

arthrodesis for severe pes cavus

deformity When deformity is severe this

technique is used.

The entire navicular is excised along

with resection of subtalar and

calceneocuboid joints along with some

portion of bone is involved.

Foot ( expect talus ) is displaced

posteriorly at subtalar joints so head of

talus is apposed to cuneiform.

Hoke and kite method

The head and neck of talsu is excised along with inferior surface of talus with corresponding articular superior calceneal surface.

The soft tissue attachments of head and neck of talus are cut.

Kite method also fuses calceneocubiodjoints

The deformity is corrected and position of foot is maintained with k wire or screws

Triple arthrodesis in CTEV

Triple arthrodesis and telectomygenerally are salvage operation for uncorrected clubfoot in older child.

Two wedge are resected,one is lateral closing wedge osteotomy through the subtalr and midtarsal joints and in second wedge much the superior part of calcaneum and inferior part of talus are included.

In addition to these release of planter fascia lenghthing of TA tendon by z plasty and posterior capsule of ankle joints are done

Complications

1. Non union

TN joints non union most common

5-10 %

For decrease the chance of non

union medial incison also used for

removing all residual cartilage from

TN joint.

2. Degenerative joint disease

3.Wound healing problem

4. Nerve injuries

At risk sural nerve and superficial peronealnerve in case of lateral incision

Sapheneous nerve at risk in medial incision

5. Avascular necrosis of talus

6.Lateral instability

due to hindfut placed in varus and calceneofibular ligaments not heal properly

7.Stiff foot

8.Pseudoarthrosis

Arthroscopic triple arthrodesis

Lui et al in 2006 describe a technique for arthroscopic triple athrodesis that has six portals.

Advantages over open procedures are1.Better intraarticualr visulization2. Thorough cartilage debridement3.Preservation of bones4.Less soft tissue dissection5. Improves cosmetics results Outcomes of procedues are still not

available

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