Point-Counterpoint: Triple Arthrodesis: Is It The Standard Of Care For Hindfoot Reconstructions?
Citing the procedure’s stability and correction of deformities in multiple planes, these authors argue the triple arthrodesis is the gold standard for multiplanar hindfoot deformities.
By Ben Carelock, DPM, and Peter A. Blume, DPM, FACFAS
The human foot is an anatomically and biomechanically complex structure that must endure tremendous stresses even in normal gait. Accordingly, reconstruction of hindfoot deformities is a demanding task that requires both diagnostic and surgical acumen. When deciding to perform a hindfoot reconstruction, the surgeon should choose a procedure that is logical, powerful and reproducible.
When it comes to the surgical correction of both varus and valgus foot deformities, as well as hindfoot arthritis, only one procedure meets the aforementioned criteria: triple arthrodesis.
Triple arthrodesis is the gold standard for the treatment of neurogenic foot deformities, advanced adult-acquired flatfoot deformity, tarsal coalition and post-traumatic arthritis of the hindfoot. Studies have shown satisfaction rates to be as high as 91 to 95 percent though there was documented progression of arthritis at adjacent joints.1-3
Since Ryerson first described triple arthrodesis in 1923 for the treatment of neurogenic foot deformities, the indications have since expanded to include a broad spectrum of deformities as well as arthrosis of the hindfoot.3 While the hindfoot was originally fixated with serial casting, the development of internal fixation has greatly improved the outcomes and postoperative course of triple arthrodesis. The stability conferred by fusion of multiple joints combined with the ability to correct deformities in multiple planes makes the triple arthrodesis the ideal procedure to correct multiplanar deformities of the hindfoot.
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 applications.
Pertinent Pearls On Appropriate Patient Selection
When it comes to patient selection for triple arthrodesis, one should consider biomechanical, physiologic and social factors. Biomechanical factors include the type of deformity you are addressing, the condition of adjacent joints and the overall alignment of the foot and ankle. It has been well documented that triple arthrodesis accelerates the progression of arthritis at adjacent joints both proximally and distally.4,5 The radiographic progression of arthritis at adjacent joints, however, does not correlate with clinical outcomes or patient satisfaction scores.3-6 Even so, if there is significant degeneration at adjacent joints, triple arthrodesis may require adjunctive or alternative procedures.
Physiologic factors influencing patient selection include vascular status, nutrition status and other comorbidities. Smoking, while not an absolute contraindication, significantly increases the likelihood of adverse events, such as failure of bone and wound healing. One must consider all these factors prior to considering this procedure for a patient.7
Social factors include the ability to remain non-weightbearing for greater than six weeks as well as being able to provide an optimum environment for bone and wound healing. Additionally, if a patient is unable to take a significant amount of time out of work to recover, more conservative treatment measures may be warranted.
Reviewing The Indications And Benefits For Triple Arthrodesis
One of the more common clinical indications for triple arthrodesis is posterior tibial tendon dysfunction (PTTD). The ideal candidate for treatment of PTTD with a triple arthrodesis is a patient with hindfoot valgus and associated rigidity, but without arthritis at adjacent joints. If residual forefoot supination is present, adjunctive procedures may be required to obtain purchase of the first ray.