A Guide To The Triple Arthrodesis For Hindfoot Deformities

Kevin Dux, DPM, Sarah Edgar, DPM, and Peter Blume, DPM, FACFAS

The triple arthrodesis has evolved to become the gold standard for the correction of sometimes complex hindfoot deformities with long-term follow-up showing high satisfaction rates. Accordingly, these authors offer a closer look at the procedure, review key indications and provide pertinent pearls.

The triple arthrodesis is the gold standard procedure for correction of various causes of hindfoot deformity. The procedure has undergone an evolution over the last 90 years with changes in fixation technique ranging from internal to external fixation and the development of multiple surgical approaches. Fusion is also the procedure of choice to relieve the pain caused by arthritis of hindfoot joints.

   An examination of triple arthrodesis in various applications will demonstrate its versatility and reliability in a wide range of indications.

   Speaking in broad terms, the indications for this procedure include post-traumatic changes, inflammatory arthritides, advanced posterior tibial tendon dysfunction (PTTD), Charcot arthropathy and progressive neuromuscular disease. All of these etiologies cause a structural deformity including pes plano valgus, cavovarus, equinovarus and hindfoot varus or valgus.

   One of the most commonly encountered clinical indications for triple arthrodesis is PTTD. The ideal candidate for treatment of PTTD with the triple arthrodesis is a patient who has hindfoot valgus and associated rigidity but no arthritis at adjacent joints. If residual forefoot supination is present, adjunctive procedures including additional osteotomies or tendon transfers may be required to obtain purchase of the first ray. One must consider these concomitant procedures before approaching the triple arthrodesis in any patient.

   While the triple arthrodesis is not classically indicated for stage II PTTD, it does have a role in the treatment of supple hindfoot deformities. Overweight or obese patients with stage II PTTD may be well served with triple arthrodesis as they are unlikely to maintain stable correction over time with realignment osteotomies and tendon transfers. Triple arthrodesis for PTTD has demonstrated 70 percent good to excellent results with long-term follow-up.1 The presence of arthritis at the talonavicular, calcaneocuboid or subtalar joint may also serve as an indication for triple arthrodesis.

   The neuromuscular cavus foot is another common pathology that often does not respond well to bracing or less definitive surgical treatments. Many disease states may lead to the development of a neuromuscular foot deformity with the general end result being a cavus foot. When the neuromuscular cavus foot is in the early stages, one may perform tendon lengthening or transfers. Longstanding deformity may cause bony, soft tissue or joint remodeling, leading to a rigid deformity unresponsive to soft tissue procedures. The presence of spasticity may also preclude the use of soft tissue correction.2

   Triple arthrodesis is the procedure of choice for the correction of deformities that soft tissue procedures or corrective osteotomies may not viably treat. Surgeons may also combine triple arthrodesis with tendon transfers in the setting of anterior compartment weakness. In the case of severe deformity, one may remove corrective wedges of bone as part of the triple arthrodesis procedure.

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