triple arthrodesis seminar by dr chirag patel
TRANSCRIPT
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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