Point-Counterpoint: Triple Arthrodesis: Is It The Standard Of Care For Hindfoot Reconstructions?
Triple arthrodesis, while not classically indicated for stage II PTTD, 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 the long term with realignment osteotomies and tendon transfers. Triple arthrodesis for PTTD has demonstrated 70 percent good to excellent results with long-term follow-up.6
The presence of arthritis at the talonavicular, calcaneocuboid or subtalar joint (STJ) may also serve as an indication for triple arthrodesis.
On the opposite end of the spectrum of deformity lies the neuromuscular cavus foot. Many disease states may lead to the development of a neuromuscular foot deformity but the general end result is a cavus foot. In its early stages, neuromuscular cavus may be treated by 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.4
Triple arthrodesis is the procedure of choice for the correction of deformities that may not be viably treated with soft tissue procedures or corrective osteotomies. 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.
The use of triple arthrodesis for correction of neuromuscular cavus has been well documented with long-term follow up studies of up to 40 years.3 Satisfaction rates for treatment of neuromuscular disease with triple arthrodesis range from 23 to 95 percent though the low end of this spectrum represents patients with progressive neuromuscular dysfunction and dynamic muscle imbalance.
One of the most direct indications for triple arthrodesis is hindfoot arthritis. If there is post-traumatic, degenerative or inflammatory arthritis in one or several of the hindfoot joints, triple arthrodesis may serve to limit the pain associated with motion at these damaged joints.
Before pursuing surgical intervention, one should pursue a thorough diagnostic workup and exhaust appropriate conservative treatment. Be advised that in certain instances, clinical and radiographic findings may not correlate. If there is radiographic evidence of multiple joint arthritis but a clinical exam does not match the radiographic findings, one may use joint injections with local anesthesia to identify which joints are the source of pain.
Arthritis confined to one joint is best treated with arthrodesis of that joint alone.8 However, one should treat severe arthritis, multiple joint arthritis or arthritis associated with significant deformity with triple arthrodesis as it confers greater stability. If early degenerative changes are present at joints adjacent to the symptomatic joint, one should also pursue fusion for these joints as arthritic progression will likely occur once any of the joints in the triple joint complex is fused.
The indications for triple arthrodesis have broadened since its first description in 1923. In addition to the indications listed here, indications also include the reconstruction of neglected calcaneal fractures, late reconstruction of tarsal coalition, neglected clubfoot and a wide array of severe pathology of the hindfoot. Long-term outcomes data supports the use of triple arthrodesis in patients with severe deformities and suggests that one can obtain good and excellent outcomes with appropriate patient selection.
However, there are some key points that can increase patient satisfaction. The first is expectations management. The triple arthrodesis was, is and always will be a procedure for reconstruction of end-stage disease. By explaining that the goal is to decrease pain and improve function, not to create a disease-free foot, patients are unlikely to be surprised by some of the inevitable sequelae of the procedure. While technically demanding and not without flaws, the triple arthrodesis is still the cornerstone for reconstruction of severe hindfoot deformities.
Dr. Carelock is a second-year resident at Yale New Haven Hospital.