Point-Counterpoint: Triple Arthrodesis: Is It The Standard Of Care For Hindfoot Reconstructions?
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.
1. Schroeder SM, Sella E, O’Hara R, Blume PA. Triple arthrodesis. EMedicine Journal, Orthopedic Surgery, Foot and Ankle [serial online] 2004; 5(5).
2. Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC, Ponseti IV. Triple arthrodesis: twenty-five and forty-four-year average follow-up of the same patients. J Bone Joint Surg Am 1999; 81(10):1391-402.
3. Raikin SM. Failure of triple arthrodesis. Foot Ankle Clin N Am 2002; 7(1):121-133.
4. Pell RF, Myerson MS, Schon LC. Clinical outcome after primary triple arthrodesis. J Bone Joint Surg Am 2000; 82(1):47-57.
5. Kadakia AR, Haddad SL. Hindfoot arthrodesis for the adult acquired flatfoot. Foot Ankle Clin N Am 2003; 8(3):569-94.
6. Jarde O, Abiraad G, Gabrion A, Vernois J, Massy S. Triple arthrodesis in the management of acquired flatfoot deformity in the adult secondary to posterior tibial tendon dysfunction. A retrospective study of 20 cases. Acta Orthop Belg. 2002; 68(1):56-62.
7. Smith RW, Shen W, DeWitt S, Reischl SF. Triple arthrodesis in adults with non-paralytic disease. a minimum ten-year follow-up study. J Bone Joint Surg Am 2004; 86(12):2707-2713.
8. Burks JB, DeHeer PA. Triple arthrodesis. Clin Podiatr Med Surg 2004; 21(2):203-226.
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.
Indeed, is fusion of these three major joints the standard of care and what alternatives to triple arthrodesis are available? Even our industry partners have employed their resourcefulness, skills and technology to make available an absolute abundance of “hardware looking for procedures.” My rudimentary review of the procedural details of a triple arthrodesis serves to remind surgeons of the extent of surgical invasion, soft tissue dissection, joint/cartilage resection, mobility restriction and joint destruction involved in this procedure. The ease of hardware placement and low profile advanced materials should not lure one toward the glow of the “triple.”