Introduction
In medicine, fusion is referred to as arthrodesis. By removing the cartilage from the joint surface and building a "bone bridge" over the joint, the bones are held together during a fusion. Many painful foot abnormalities can be treated with triple arthrodesis, a fusion in the hindfoot (rear of the foot). Three ankle joints that allow the foot to move from side to side are fused during this treatment. The talonavicular, subtalar, and calcaneocuboid joints make up this group.
Although surgeons want to avoid them, there are situations when pain and deformity are so severe that this treatment has the best chance of resulting in a foot that is less painful and more properly aligned. The hindfoot fusion is a tried-and-true, long-lasting surgery.
What Are the Indications of Triple Arthrodesis?
Indications for triple arthrodesis include:
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Painful degenerative or posttraumatic arthritis (a form of osteoarthritis caused by a fracture or dislocation of the bone).
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End-stage flatfoot (when people stand up, the inside arch of the feet is flattened, allowing the entire foot to contact the ground) deformities.
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Pes Cavus deformitiesis a term used to describe a foot morphology characterized by a high arch that does not flatten under weight.
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Tarsal coalition (a misplaced foot bone contact involving two or more bones) in case of secondary severe degenerative joint disease or resection failure.
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Residual clubfoot deformities - The foot is stiff and has almost invariably already undergone surgery.
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Non-acute Charcot arthropathyis a musculoskeletal disorder that worsens over time and is marked by pathological fractures, severe deformities, and joint dislocations.
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Other neurological conditions result in a propulsive gait (for example., poliomyelitis, cerebral palsy).
What Are the Contraindications of Triple Arthrodesis?
To get the best results, like with any treatment, thorough patient selection and post-operative goal management are essential. Some absolute contraindications to triple arthrodesis are:
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Arterial insufficiency.
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The presence of an active infection.
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Acute Charcot Arthropathy - On physical examination, the following findings are observed in patients with acute Charcot arthropathy:
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Pounding pedal pulses (pulsation in the foot).
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Elevated lower extremity temperatures.
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Localized edema (swelling).
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Lack of protecting feelings in acute Charcot arthropathy.
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Moreover, the likelihood of this diagnosis is raised by a positive history of neuropathy, radiographs demonstrating disordered osteolysis, and laboratory indicators, including an elevated ESR (erythrocyte sedimentation rate).
Some relative contraindications are:
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Uncontrolled comorbidities.
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Ankle arthritis.
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No prior experience with conservative therapy.
What Happens During a Triple Arthrodesis Procedure?
The surgeon will start by placing the patient in a supine position so that the entire foot can be seen. In order to ensure that patients do not feel any pain during the surgery, an anesthetic will be given. Before making the incision, the surgical site will be cleansed and sterilized.
A second incision will be made on the inside of the ankle after the first one is made on the outside of the foot, slightly below the ankle. The remaining cartilage between the bones of these joints is removed after the surgeon examines the underlying joints.
If the hindfoot is out of place, it will be fixed by stabilizing the bone joints with screws, staples, or plates. When necessary, a bone graft is placed all the way around the gap between the bones.
How Is Triple Arthrodesis Done?
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With a thigh tourniquet (a cloth or a band of rubber), the patient usually lies on their back. It is advised to use a general anesthetic.
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Starting at the distal tip of the fibula (calf bone) and continuing to the base of the fourth and fifth metatarsals (foot bones), the treatment is carried out lateral to the sural and intermediate dorsal cutaneous nerves (nerves of the ankle joint). The incision is deepened until the fascia (sheet of connective tissue) covering the extensor digitorum brevis muscle (foot muscles) is reached. At this stage, it may be necessary to sacrifice a sural nerve (nerve of the lower leg) branch that communicates with the intermediate cutaneous branch in order to move forward. The extensor digitorum brevis muscle is then reflected off of the sinus tarsi where it originated.
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Then, it may be possible to locate and excavate the sinus tarsi. For proper subtalar joint exposure, fibrofatty tissue in the sinus tarsi (Hoke's tonsil) should be removed. To reveal the anterior and center aspects of the subtalar joint, all attachments, including the interosseous ligament, must be removed.
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Once the previous incision has been made distally, the calcaneal cuboid (foot joint) joint will be visible, and its dorsal ligaments must be loosened.
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The medial incision will then be made between the ankle's medial gutter and extended to the navicular's inferior aspect. This region frequently contains the superiorly retractable great saphenous vein (blood vessels of the legs). The connection of the posterior tibial tendon can be preserved by incising the talonavicular joint's capsular tissue in line with the incision. The whole aspect of the joint can often be exposed with the help of a Cobb elevator.
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A number of techniques can be used to resect the talonavicular joint. In order to remove cartilage and expose subchondral bone while preserving the joint's original form, curettes or osteotomes may be employed. In order to guarantee a successful osseous union, it is essential to do adequate cartilage resection and bone fenestration.
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Resection at the calcaneocuboid joint then begins once the talonavicular joint has been prepared. Again, curettes, osteotomes, or sagittal saws are available as choices. A calcaneus wedge can be used for correction if the foot has a transverse plane deformity.
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The subtalar joint is prepared for arthrodesis at this point. To provide appropriate subchondral bone exposure, the posterior facet can be prepared using curettage, an osteotome, or a rotary bur. This technique can also be used to resect the central facet if it has been exposed. If a bone graft is used for wedging, the deformity can be corrected by placing it there.
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The talonavicular joint can be manually moved after all joints have been prepared, and then it can be temporarily fixed with Kirschner wires or Steinmann pins. The calcaneocuboid and subtalar joint can then be temporarily fixed using the same techniques.
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The subtalar joint is then fixed permanently after ensuring that the foot is in the ideal position for fusion. Screws can be utilized to secure the calcaneus from a posterior and lateral angle, reaching the dorsal medial part of the talus. Screws inserted from the inferior and distal portion of the navicular into the head of the talus can subsequently be used to fixate the talonavicular joint. It is now possible to fixate the calcaneocuboid joint using a number of hardware methods.
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The final position of the foot should have the midtarsal joint somewhat valgus (turned outward away from the midline) and the heel in neutral to modest eversion (outward turn).
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After that, incisions are irrigated and anatomically layered closed. Many techniques can be used to close the skin. It is possible to utilize a drain to stop hematoma formation. Following the treatment, patients are normally non-weight bearing and placed in a splint.
How Is the Recovery After the Triple Arthrodesis Procedure?
The speed of healing varies and depends on a number of variables. In order to reduce swelling and promote skin healing, the foot is typically put into a splint and kept elevated while not bearing any weight for the first two weeks. Within two to three weeks following surgery, stitches may be removed.
There are many weight-bearing procedures that can be applied. Progressive weight bearing is permitted until full weight bearing is achieved when healing indicators have been identified. Normally, this takes three months. A cast could be applied to the foot during this procedure. A removable boot may occasionally be used in place of a cast.
What Are the Complications of Triple Arthrodesis Surgery?
Once the surgeons have successfully fused the bones, the majority of patients are happy with their results. The majority really believes that the diminished range of motion is a fairly acceptable trade-off for pain relief. All surgical procedures carry a risk of potential problems, such as:
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Those related to anesthesia.
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Infection.
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Injury to the nerves and blood vessels.
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Bleeding or blood clots.
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Wound breakdown or infection are the most frequent complications in the first two to three weeks.
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Non-union of bones - There is a chance that the bones would not fuse (a non-union). Smoking may increase the chance of non-union.
Some ways to prevent complications are:
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Avoiding smoking.
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Elevating the foot.
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Putting no weight on it.
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Maintaining a clean, dry surgical dressing.
The most frequent long-term effect of triple arthrodesis is the arthritic progression of other joints in the foot and ankle. Many of these alterations never become obvious to the patient because they take years or even decades to develop.
What Is the Clinical Significance of Triple Arthrodesis?
Many foot disorders and gait abnormalities can benefit from triple arthrodesis. The operation is frequently utilized as a conclusive treatment for numerous foot deformities due to its predictability, which allows patients to walk with little pain. In a study, 95 percent of patients who followed individuals who underwent triple arthrodesis were happy with the results. Although it has drawbacks, the subsequent loss of range of motion might make other procedures a wiser choice. This surgery may be appropriate for many patients with advanced foot abnormalities.
Conclusion
Even with a person's normal walk, the foot must withstand a great deal of stress due to its complex anatomical and biomechanical design. Therefore, restoration of hindfoot abnormalities is a challenging task that demands both diagnostic and surgical skills. In the field of podiatry, triple arthrodesis has proven to be a dependable, effective, and repeatable surgery for treating a wide range of common diseases. The treatment has a wide range of uses and has produced consistently high levels of patient satisfaction for patients with end-stage disease through a number of revisions over the years.
