Triple arthrodesis

1. TRIPLE ARTHRODESIS
Ponnilavan

2. Anatomy of Foot:

4. Triple arthrodesis:
• Fusion of subtalar,
calcaneocuboid, and
talonavicular joint.
• Aim:
Provide hindfoot
stability
• Provide
hindfoot alignment
• Relieve pain

5. Indications:
• Rheumatoid arthritis
• Post traumatic
arthritis
• Osteoarthritis
• Charcot's marie tooth
disease
• Neglected club foot
• Poliomyelitis
• Tarsal coalition

6. Contraindications:
• Young child less than 12 years
• Inadequate blood supply
Surgery is offered when nonoperative
measures have failed to alleviate the
symptoms

7. Preperative Planning:
• Proper history and
examination should be
undertaken
• Observe the patient in
standing position
anteriorly and posteriorly
demonstrates deformity
• Cavus Foot - NM cause
• Single leg heel raise test -
unable to perform
(Posterior tibial tendon
dysfunction)

8. • Weight bearing radiographs
To evaluate relationship between tarsal
bones
To identify morphological
abnormalities and degenerative changes
To identify location of deformity
Help to plan for location of wedge resection

9. Approach:
• Depends on type of
deformity
• Lateral (Olliers
approach) -
Neglected club foot
• Medial -
Calcaneovalgus foot
• Double incision
approach - no
signicant deformity
• Lambrinudi - severe
equinus deformity

10. Lambriduni procedure - club foot:
• Lateral Skin incision from tip
of lateral malleolus to base of
4th meatarsal
• Extensor tendons are
retracted medially and sural
nerve is mobilized and
protected

11. • EDB is elevated off
and reflected
• Exposing sinus tarsi ,
calcaneocuboid and
lateral aspect of
talonavicular joint
• Soft tissues are
cleared promotes
visualization of facets
of subtalar joint

12. 1. Calcaneocuboid
resection
Remove a lateral
wedge to shorten the
lateral border of foot
Osteotome used
to make a cut
transverse to long axis
of calcaneum
second cut is joint
surface of cuboid and
should be conservative

13. 2. Resection of neck
and head of talus
Cut begins at
superior margin of
articular surface of talus
extends in proximal and
plantar through inferior
potion of talar neck

14. 3. Completes the wedge resection and lies
along anterior surface of calcaneus parallel
to long axis of forefoot in sagital plane
Facilitates dorsiflexion of forefoot to
achieve plantigrade position

15. 4.Conservative resection
articular surface of
navicular
notch in inferior
articular surface of navicular
to accept anterior portion of
talus
anterior end of talus
is pushed into notch under
navicular while abducting
forefoot
5.Fixation of joints with K
wire, staples and screws
6.Lengthening of TA tendon
by Z plasty

16. Other procedures:
• Beak triple arthrodesis
• Dunn arthrodesis
• Hoke kite arthrodesis
• Inlay grafting method

17. •

18. Postoperative protocol:
• Limb is typically immobilised in a short or long cast for
atleast 6 weeks
• Weight bearing is permitted after 6 weeks
• Ankle foot orthosis required in patient with NM disease
Week 2: wound check and remove the suture if incision is
healed
Radiographs:
1)week 6 - Good posture and evidence of healing
2)3 months - Progression of healing
3) 6 months - To confirm full union

19. Complications:
• Injury to neurovascular or tendinous
structures
• Wound infection
• Wound breakdown or skin necrosis
• Pseudoarthrosis
• Recurrent deformity in NM disease
• Pain from persistent malalignment,
degenerative changes and avascular
necrosis of talus

20. References:
1. Comprehensive orthopaedic surgery
Chapman's Volume 3
2.Operative techniques in orthopaedic
surgery Weisel 2 nd edition