The triple arthrodesis has evolved to become the gold standard for the correction of sometimes complex hindfoot deformities with long-term follow-up showing high satisfaction rates. Accordingly, these authors offer a closer look at the procedure, review key indications and provide pertinent pearls.
The triple arthrodesis is the gold standard procedure for correction of various causes of hindfoot deformity. The procedure has undergone an evolution over the last 90 years with changes in fixation technique ranging from internal to external fixation and the development of multiple surgical approaches. 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 indications.
Speaking in broad terms, the indications for this procedure include post-traumatic changes, inflammatory arthritides, advanced posterior tibial tendon dysfunction (PTTD), Charcot arthropathy and progressive neuromuscular disease. All of these etiologies cause a structural deformity including pes plano valgus, cavovarus, equinovarus and hindfoot varus or valgus.
One of the most commonly encountered clinical indications for triple arthrodesis is PTTD. The ideal candidate for treatment of PTTD with the triple arthrodesis is a patient who has hindfoot valgus and associated rigidity but no arthritis at adjacent joints. If residual forefoot supination is present, adjunctive procedures including additional osteotomies or tendon transfers may be required to obtain purchase of the first ray. One must consider these concomitant procedures before approaching the triple arthrodesis in any patient.
While the triple arthrodesis is not classically indicated for stage II PTTD, it 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 time with realignment osteotomies and tendon transfers. Triple arthrodesis for PTTD has demonstrated 70 percent good to excellent results with long-term follow-up.1 The presence of arthritis at the talonavicular, calcaneocuboid or subtalar joint may also serve as an indication for triple arthrodesis.
The neuromuscular cavus foot is another common pathology that often does not respond well to bracing or less definitive surgical treatments. Many disease states may lead to the development of a neuromuscular foot deformity with the general end result being a cavus foot. When the neuromuscular cavus foot is in the early stages, one may perform 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.2
Triple arthrodesis is the procedure of choice for the correction of deformities that soft tissue procedures or corrective osteotomies may not viably treat. 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 strongest 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.
Surgeons can best treat arthritis confined to one joint with arthrodesis of that joint alone. However, when it comes to severe arthritis, multiple joint arthritis or arthritis associated with significant deformity, one should perform a triple arthrodesis as it confers greater stability.
Use caution in performing an isolated talonavicular fusion as this is associated with a risk of nonunion and leaves the surgeon with limited options for correction because of bone loss and erosion.4 In performing limited arthrodesis of the talonavicular and subtalar joints, there is potential for inferior subluxation of the cuboid relative to the calcaneus.4 If early degenerative changes are present at joints adjacent to the symptomatic joint, surgeons should also pursue fusion for these joints as arthritic progression will likely occur once one fuses any of the joints in the triple joint complex.
In addition to the aforementioned indications, other indications for the triple arthrodesis 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.5,6
What The Research Says About Incision Approaches
The literature has described three different incisional approaches for the triple arthrodesis. The classic approach is the two-incision approach, which allows for easy visualization of the joints. More recent literature has described both the medial and lateral approaches. The medial approach has had equal surgical outcomes with no increase in surgical durations.7 However, authors also note that one should reserve the medial approach for patients with lateral skin compromise, such as those with rheumatoid arthritis.7
Cadaveric studies have shown that a purely lateral approach can remove only 38 percent of cartilage from within the talonavicular joint.8 Study authors attributed this to a poor appreciation of the anatomy of the talar head and poor surgeon observation. Although surgeons removed 90 percent of cartilage from the calcaneocuboid joint and 80 percent from the talocalcaneal joint, the poor access to the talonavicular joint makes it impossible to recommend the lateral approach as it could lead to a nonunion of the talonavicular joint.
A Brief Guide To Surgical Technique
Regardless of the approach, it is important to emphasize careful anatomic dissection while taking care not to damage the numerous vital structures one will encounter through the extensive dissection needed for adequate exposure. When using a lateral approach, avoid damaging the sural nerve, peroneal tendons and superficial peroneal nerve. Retract the tibialis anterior and neurovascular bundle while working through the medial incision.
Joint preparation can occur several different ways, including resection of the joints with a saw or osteotome. In cases of severe deformity, one must resect wedges of bone to reduce the deformity adequately. Lambrinudi first described this in 1927 as reported by Bernau.9 Surgeons have continued to use this technique today with excellent success. Alternatively, one can use a rotary burr.
We recommend preparing the joint surfaces with curettage to avoid thermal necrosis of the fusion surfaces followed by fish scaling and fenestration with a 1.5 mm or 2.0 mm drill.
Fixation is largely surgeon dependent with no statistically significant difference between modern fixation techniques, which include screws, staples and plates.10 One can use external fixation in combination with internal fixation or alone. Indications for external fixation for triple arthrodesis include patients with poor bone stock, such as those with Charcot deformity or infection. In 2004, Treadwell showed promising results using an external fixation system in eight patients to allow earlier axial weightbearing.11
A study by Talarico looked at 87 patients undergoing triple arthrodesis with external ring and arched wire compression as the method of fixation.12 All patients were partially weightbearing within the first week postoperatively and 97 percent achieved clinical and radiographic fusion in six to eight weeks. Three of these patients experienced an asymptomatic nonunion and patients in both studies had issues with pin tract drainage and infection. Even with these complications, these studies indicate that with correct patient selection, external fixation does provide a good additional option for fixation.11,12
Keys To Emphasizing Proper Patient Selection
Before pursuing surgical intervention, the physician should pursue a thorough diagnostic workup and exhaust appropriate conservative treatment options. 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.
As with any elective surgery, consider the general health of the patient preoperatively. Contraindications to this procedure are the same as for any other major arthrodesis procedure. Factors to consider when delaying surgery include poor nutrition status, endocrine abnormalities, inadequate peripheral flow and active smoking status. The ability to remain non-weightbearing for a significant period of time is also a primary concern in patient selection for this procedure.
A Guide To Post-Op Care And Possible Complications
Postoperatively, patients should expect to be completely non-weightbearing for at least six weeks. Apply a posterior splint until there are signs of incision skin healing. Then transition the patient to a cast or removable controlled ankle motion (CAM) boot for 12 weeks. If clinical and radiographic signs of healing are present, progressive weightbearing can begin at week seven as tolerated. Physical therapy can start at week 12. Patients undergoing triple or ankle fusion should avoid high impact sports and torsional loading in order to reduce the risk of accelerated secondary arthrosis in surrounding joints, arthrodesis failure or stress fracture.13
Like any reconstructive surgery, there are a number of complications that can occur following a triple arthrodesis. These include but are not limited to: wound dehiscence, infection, sural neuralgia, prominent hardware, persistent pain and arthritis of the adjacent proximal and distal joint.
What Long-Term Follow-Up Reveals On Patient Satisfaction
Since the development of the procedure in 1921, there has been ample time to perform longitudinal studies to determine outcomes and patient satisfaction with the triple arthrodesis. Despite the amount of restriction and long postoperative course, a triple arthrodesis has a very high patient satisfaction rate. Multiple studies have been published on the results of triple arthrodesis from five years to long-term follow up of up to 44 years with satisfaction rates as high as 95 percent (see the table “A Closer Look At Long-Term Studies” at left).2,5,6
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 goals are 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.
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. The triple arthrodesis has proved to be a reliable, powerful and reproducible procedure for the treatment of a wide variety of common pathologies in the podiatric practice. The procedure has many different applications and, through various modifications over the years, has continued to produce very high satisfaction rates for patients with end-stage disease.
Dr. Dux is a third-year resident at Yale-New Haven Hospital in New Haven, Conn.
Dr. Edgar 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. Dr. Blume is a Fellow of the American College of Foot and Ankle Surgeons.
1. 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.
2. Pell RF, Myerson MS, Schon LC. Clinical outcome after primary triple arthrodesis. J Bone Joint Surg Am. 2000; 82(1):47-57.
3. Raikin SM. Failure of triple arthrodesis. Foot Ankle Clin N Am. 2002; 7(1):121-133.
4. Myerson MS. Reconstructive Foot and Ankle Surgery: Management of Complications. Second edition. Elsevier Saunders, Philadelphia, 2010, pp. 467-468.
5. Smith RW, Shen W, DeWitt S, Reischl SF. Triple arthrodesis in adults with non-paralytic disease: a minimum 10-year follow up study. J Bone Joint Surg Am. 2004; 86(12):2707-2713.
6. Saltzman CL, Fehrle MJ, Cooper RR. 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.
7. Weinraub G, Schuberth J, Lee M, Rush S, Ford L, et al. Isolated medial incisional approach to subtalar and talonavicular arthrodesis. J Foot Ankle Surg. 2010; 49(4):326-330.
8. Bono JV, Jacobs RL. Triple arthrodesis through a single lateral approach: a cadaveric experiment. Foot Ankle. 1992; 13(7):408-12.
9. Bernau A. Long-term results following Lambrinudi arthrodesis. J Bone Joint Surg Am. 1977; 59(4):473-479.
10. Payette C, Sage R, et al. Triple arthrodesis stabilization: A quantitative analysis of screw versus staple fixation in fresh cadaveric matched-pair specimens. J Foot Ankle Surg. 1998; 37(6):472-480.
11. Treadwell JR. Triple arthrodesis with an external rail fixator: a review of 8 cases. J Foot Ankle Surg. 2004; 43(6):400-406.
12. Talarico LM, Vito GR. Triple arthrodesis using external ring fixation and arched-wire compression: an evaluation of 87 patients. J Am Podiatr Med Assoc. 2004; 94(1):12-21.
13. Vertullo CJ, Nunley JA. Participation in sports after arthrodesis of the foot or ankle. Foot Ankle Int. 2002; 23(7):625-628.
For further reading, see “Point-Counterpoint: Triple Arthrodesis: Is It The Standard Of Care For Hindfoot Reconstructions?” in the January 2011 issue of Podiatry Today.