Point-Counterpoint: Triple Arthrodesis: Is It The Standard Of Care For Hindfoot Reconstructions?

Author(s): 
Ben Carelock, DPM, Peter A. Blume, DPM, FACFAS, and Christopher Hendrix, DPM, FACFAS

   In reviewing the available literature, it does appear that triple arthrodesis is the standard finishing surgical intervention for advanced hindfoot pathology, pain, deformity and limitation. However, in reviewing the literature, the reader must consider the patient population presented and consider the actual numbers of patients available for review and wonder in contrast about the numbers of patients treated in a non-operative, non-triple arthrodesis fashion.

Surveying The Options For Conservative And Surgical Care

When assisting the patient with a viable, therapeutic and realistic treatment regimen, the spectrum of care should include benign neglect and observation, conservative care and surgical, albeit staged, intervention.

   Benign neglect is a reasonable approach for many patients. In offering benign neglect as an option of care, the physician has thoughtfully reviewed the patient’s medical history, chief complaint and history, and physical findings and correlated those with diagnostic studies to objectify the patient’s deformity, prognosis and level of discomfort. Benign neglect and observation does not rule out intervention of any kind, but merely allows the patient some sense of control and fully informs the patient of the condition while considering the whole medical presentation and preclusions to operative intervention.

   Conservative, non-operative care focused on symptomatic relief is certainly a valuable, viable and much appreciated option. The physician and patient together employ and exhaust non-operative options to maintain a thoroughly productive though perhaps limited lifestyle. This lifestyle allows the patient to continue to be dynamic both at home and at work without the potentially prolonged interruption of surgery, recovery and convalescence. Again, considering the host of entities and the whole medical presentation, the clinician must ensure the patient maintains a reasonable activity level and is able to proceed with the regular activities of daily living. Weight maintenance or weight loss may be a significant and realistic concern for the patient. One should absolutely address diminished smoking and smoking cessation with realistic and achievable goals.

   A variety of treatment modalities and options are certainly available to the physician and patient. These include topical and oral analgesics and/or topical and oral non-steroidal anti-inflammatory drugs (NSAIDs), limited bracing, ankle-foot orthoses (AFOs), shoe modifications, articulated bracing and brace-on shoes.

   Certainly, in offering operative care, one should review a spectrum of surgical options with the patient. The physician must thoroughly review the potential operative risks and complications in addition to benefits and treatment alternatives, procedural details, realistic expectations, recovery, recuperation, rehabilitation and convalescence with patients and their family members.

   Operative care may include simple palliative procedures, debridements and “clean-ups,” soft tissue procedures, osseous procedures, isolated and limited fusions, triple arthrodesis and amputation. Certainly, the list of potential procedures can include arthroscopic debridement, tenosyonvectomy, cartilage replacement/osteoarticular transfer system (OATS) and distraction arthrodiastasis. When considering triple arthrodesis, one must address the potential effects on the pedal and ankle joints “fore and aft.”

In Conclusion

Given the considerations outlined above, I would argue that triple arthrodesis is not the obvious standard of care for the treatment of hindfoot pathology. Rather, triple arthrodesis is a component of the treatment algorithm for patients presenting with rearfoot deformities, pathology or pain.

   Dr. Hendrix is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified by the American Board of Podiatric Surgery and the American Academy of Wound Management. He is in private practice at Mid-South Foot and Ankle Specialists in Tennessee.

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