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.
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.
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.
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.
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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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.
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.”
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.
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.”
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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