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Triple arthrodesis seminar by Dr Chirag Patel
- 1. Triple Arthrodesis Dr ChiragPatel Department of Orthopaedics St Stephen’s Hospital
- 2. Introduction The mosteffective stabilizing procedure in the foot is triple arthrodesis ,fusion of the subtalar, calcaneocuboid, and talonavicular joints. Triple arthrodesis limits motion of the foot and ankle to plantar flexion and dorsiflexion.
- 3. History Edwin Ryersonfirst described classical triple arthrodesis in 1923 as fusion of all three joints,he said “ the main aim of this type of operation is improvement of function of the foot. Lambrinudi described his operation in 1927. The goal was to create a well aligned plantigrade and stable foot that would allowe pt with paralytic or deforming condition to better function
- 4. The mostcommon indications were to correct lower limb deformity in child resulting from polio,cerebral palsy , charcot marie tooth disease,clubfoot. The original procedure was performed by removing large blocks of subchondral bone and correcting angular deformity by inserting or removing wedges.correction was maintained by cast that often required later manipulation for loss of position
- 5. Indications to obtainstable and static realignment of the foot, to remove deforming forces, to arrest progression of deformity, to eliminate pain, to eliminate the use of a short-leg brace or to provide sufficient correction to allow fitting of a long-leg brace to control the knee joint, and to obtain a more normal-appearing foot
- 6. Generally, triplearthrodesis is reserved for severe deformity in children 12 years old and older; occasionally, it may be required in children 8 to 12 years old with progressive, uncontrollable deformity.
- 7. Indications Post traumaticarthrits Degenerative arthritis Ctev Polio Ra Pes cavus Pes planovalgus deformity Cp Tarsal coalition Muscular dystrophy Charcot’s arthropathy
- 8. Contraindication Young childless than 12 yrs because the procedure limits growth of foot,also bones are cartilagineous in nature at this age and attempt to fuse leads to avn of talus and fibrous union instead of bony union. Relative C/I conditions are adequately corrected and maintained via bracing soft tissue procedure and tendon balancing. Chronic smoking
- 9. Preop planing Apaper tracing can be made from a lateral radiograph of the ankle, and the components of the subtalar joint are divided into three sections: the tibiotalar and calcaneal components and another component comprising all the bones of the foot distal to the midtarsal joint. These are reassembled with the foot in the corrected position so that the size and shape of the wedges to be removed can be measured accurately.
- 10. Talipes equinovarus Intalipes equinovarus, the enlarged talar head lies lateral to the midline axis of the foot and blocks dorsiflexion. A laterally based subtalar wedge, combined with midtarsal joint resection, places the talar head slightly medial to the midline axis of the foot
- 11. Talipes calcaneocavus Intalipes calcaneocavus, the arthrodesis should allow posterior displacement of the foot at the subtalar joint. After stripping of the plantar fascia, a wedge-shaped or cuneiform section of bone is removed to allow correction of the cavus deformity, and a wedge of bone is removed from the subtalar joint to correct the rotation of the calcaneus
- 12. Talipes equinovalgus ,the medial longitudinal arch of the foot is depressed, the talar head is enlarged and plantar flexed, and the forefoot is abducted. Raising the talar head and shifting the sustentaculum tali medially beneath the talar head and neck restores the arch. A medially based wedge consisting of a portion of the talar head and neck is excised . When the hindfoot valgus deformity is cor- rected, the forefoot tends to supinate; this is controlled by midtarsal joint resection with a medially based wedge. An additional medial incision may be required for resection of the talonavicular joint.
- 13. Surgical Approach OLLIER APPROACHTO THE TARSUS The Ollier approach is excellent for a triple arthrodesis: The three joints are exposed through a small opening without much retraction, and the wound usually heals well because the proximal flap is dissected full thickness and the skin edges are protected during retraction
- 14. 1st stape isto palpate all three joints Begin the skin incision over the dorsolateral aspect of the talonavicular joint, extend it obliquely inferoposteriorly, and end it about 2.5 cm inferior to the lateral malleolus Divide the inferior extensor retinaculum in the line of the skin incision . In the superior part of the incision, expose the long extensor tendons to the toes and retract them medially, preferably without opening their sheaths.
- 15. In theinferior part of the incision, expose the peroneal tendons and retract them inferiorly. Divide the origin of the extensor digitorum brevis muscle, retract the muscle distally, and bring into view the sinus tarsi. Extend the dissection to expose the subtalar, calcaneocuboid, and talonavicular joints.
- 16. Principles of classicaltriple arthrodesis Three joints are exposed by above mentioned approache follewed by joint resection and fixation. Resections of mid tarsal joints are usually performed first as it provides increase soft tissue relaxation and further facilitates better exposure of the subtalar joints. Care should taken to leave as much bone as possible at this joints specially in valgus deformity because lateral column length is imp for correction
- 17. Complete removalof articular cartilage of TN joint is must , if not possible from the classical lateral incision then made medial incison to, because most common complication of the triple arthrodesis is non union of TN joints which requires re-do triple arthrodesis often. Subtalar joints should be placed 4’ valgus relatives to ground
- 18. Fixations canbe done by k-wire steples or canulated screws. Surgical sites are closed in layers with care taken to repair the calcaneofibular ligaments and EDB muscle. A lateral drain may be used to help prevent hematoma formation specially when the large portions of bone resected.
- 20. LAMBRINUDI ARTHRODESIS TheLambrinudi arthrodesis is recommended for correction of isolated fixed equinus deformity in patients older than 10 years. Retained activity in the gastrocnemius-soleus, combined with inactive dorsiflexors and peroneals, causes the footdrop deformity. The posterior talus abuts the undersurface of the tibia, and the posterior ankle joint capsule contracts to create a fixed equinus deformity.
- 21. . Inthe Lambrinudi procedure, a wedge of bone is removed from the plantar distal part of the talus so that the talus remains in complete equinus at the ankle joint while the remainder of the foot is repositioned to the desired degree of plantar flexion. Tendon resection or transfer may be necessary to prevent varus or valgus deformity if active muscle power remains. The Lambrinudi arthrodesis is not recommended for a flail foot or when hip or knee instability requires a brace.
- 22. A goodresult depends on the strength of the dorsal ankle ligaments. If anterior subluxation of the talus is noted on a weight-bearing lateral radiograph, a two- stage pantalar arthrodesis is recommended. Complications of the Lambrinudi arthrodesis include ankle instability, residual varus or valgus deformities caused by muscle imbalance, and pseudarthrosis of the talonavicular joint
- 23. TECHNIQUE With thefoot and ankle in extreme plantar flexion, make a lateral radiograph and trace the film. Cut the tracing into three pieces along the outlines of the subtalar and midtarsal joints; from these pieces the exact amount of bone to be removed from the talus can be determined with accuracy before surgery. In the tracing, the line representing the articulation of the talus with the tibia is left undisturbed but that corresponding to its plantar and distal parts is to be cut so that when the navicular and the calcaneocuboid joint are later fitted to it the foot will be in 5 to 10 degrees of equinus relative to the tibia. unless the extremity has shortened; more equinus may then be desirable. Expose the sinus tarsi through a long, lateral curved incision.
- 26. Section theperoneal tendons by a Z-shaped cut, open the talonavicular and calcaneocuboid joints, and divide the interosseous and fibular collateral ligaments of the ankle to permit complete medial dislocation of the tarsus at the subtalar joint. With a small power saw (more accurate than a chisel or osteotome), remove the predetermined wedge of bone from the plantar and distal parts of the neck and body of the talus. Remove the cartilage and bone from the superior surface of the calcaneus to form a plane parallel with the longitudinal axis of the foot. Next make a V-shaped trough transversely in the inferior part of the proximal navicular and denude the calcaneocuboid joint of enough bone to correct any lateral deformity.
- 27. Firmly wedgethe sharp distal margin of the remaining part of the talus into the prepared trough in the navicular and appose the calcaneus and talus. Take care to place the distal margin of the talus well medially in the trough; otherwise, the position of the foot will not be satisfactory. The talus is now locked in the ankle joint in complete equinus, and the foot cannot be further plantar flexed. Insert smooth Kirschner wires for fixation of the talonavicular and calcaneocuboid joints. Suture the peroneal tendons, close the wound in the routine manner, and apply a cast with the ankle in neutral or slight dorsiflexion.
- 28. POSTOPERATIVE CARE Thecast and sutures are removed at 10 to 14 days, and the position of the foot is evaluated by radiographs. If the position is satisfactory, a short-leg cast is applied, but weight bearing is not allowed for another 6 weeks, after which a short-leg walking cast is applied and is worn until fusion is complete, usually at 3 months.
- 29. Triple arthrodesis forvarus deformity
- 30. Triple arthrodesis forvalgus deformity
- 31. Pes cavus Calceneocavovarusor cavovarus deformity mostly seen in charcot marie tooth disease and sometimes seen in polio and malunited fracture talus. Can be managed by these procedure Siffert,forster and nachami arthrodesis Dunn arthrodesis Hoke kite arthrodesis
- 32. Siffert,forster and nachami arthrodesis Wedge of bone is removed by osteotomy from midtarsal and subtalar joints. Superior part of talar head is retained to form “beak” ,dosral part of navicular is included in the osteotomy. Soft tissue structure anterior to ankle joint are left undistured. Fore foot is then displaced plantarward and navicular is locked beneth remaining part of talus head.
- 33. Dunn method oftriple arthrodesis for severe pes cavus deformity When deformity is severe this technique is used. The entire navicular is excised along with resection of subtalar and calceneocuboid joints along with some portion of bone is involved. Foot ( expect talus ) is displaced posteriorly at subtalar joints so head of talus is apposed to cuneiform.
- 35. Hoke and kitemethod The head and neck of talsu is excised along with inferior surface of talus with corresponding articular superior calceneal surface. The soft tissue attachments of head and neck of talus are cut. Kite method also fuses calceneocubiod joints The deformity is corrected and position of foot is maintained with k wire or screws
- 37. Triple arthrodesis inCTEV Triple arthrodesis and telectomy generally are salvage operation for uncorrected clubfoot in older child. Two wedge are resected,one is lateral closing wedge osteotomy through the subtalr and midtarsal joints and in second wedge much the superior part of calcaneum and inferior part of talus are included. In addition to these release of planter fascia lenghthing of TA tendon by z plasty and posterior capsule of ankle
- 38. Complications 1. Non union TNjoints non union most common 5-10 % For decrease the chance of non union medial incison also used for removing all residual cartilage from TN joint. 2. Degenerative joint disease 3.Wound healing problem
- 39. 4. Nerve injuries Atrisk sural nerve and superficial peroneal nerve in case of lateral incision Sapheneous nerve at risk in medial incision 5. Avascular necrosis of talus 6.Lateral instability due to hindfut placed in varus and calceneofibular ligaments not heal properly 7.Stiff foot
- 40. Arthroscopic triple arthrodesis Lui et al in 2006 describe a technique for arthroscopic triple athrodesis that has six portals. Advantages over open procedures are 1.Better intraarticualr visulization 2. Thorough cartilage debridement 3.Preservation of bones 4.Less soft tissue dissection 5. Improves cosmetics results Outcomes of procedues are still not available
- 41.