Point-Counterpoint: Triple Arthrodesis: Is It The Standard Of Care For Hindfoot Reconstructions?
- Volume 24 - Issue 1 - January 2011
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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.
Dr. Blume is an Assistant Clinical Professor of Surgery in the Department of Orthopaedics and Rehabilitation at the Yale University School of Medicine. He is the Director of Limb Preservation at the Yale New Haven Hospital in New Haven, Conn. Dr. Blume is a Fellow of the American College of Foot and Ankle Surgeons.
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Although triple arthrodesis is part of the treatment algorithm for those with rearfoot deformity, this author says it is not the standard of care for hindfoot pathology and warns against using triple arthrodesis as a “knee-jerk” surgical procedure.
By Christopher Hendrix, DPM, FACFAS
Before deciding on a standard of care for hindfoot reconstruction, the foot and ankle surgeon must decide and decipher the various aspects of hindfoot pathology and the clinical entities that are pertinent to this question and debate.
There is an absolute plethora of pathology that would lead the clinician to guide and counsel a patient toward a “definitive procedure” such as triple arthrodesis. In some cases, triple arthrodesis is a knee-jerk surgical offering for advanced hindfoot pathology. Several common clinical presentations vary in the degree of rearfoot involvement. Rheumatoid arthritis, traumatic arthrosis, Charcot osteoarthropathy, progressive neuromuscular disorders and late-stage posterior tibial tendon derangement are just a few presentations that obligate the practitioner to offer definitive surgical treatment.
Triple arthrodesis involves resection and fusion of the various articular surfaces involving the facets of the subtalar joint, calcaneocuboid joint and resection and fusion of the “acetabulum pedis,” commonly known as the talonavicular joint. By any account, triple arthrodesis is a pan calcaneal fusion, which involves total fusion in front of and beneath the talus, and significant restriction of the tarsal navicular and tarsal cuboid. Historically, triple arthrodesis has equaled the triple crown of foot fusions and is indeed the coup de grace of foot and ankle surgery.