Tag Archives: union

by Alan Kidon, DPM, AACFAS¹; Elizabeth Sanders DPM, AACFAS, FACFAOM^2*; Mark Mendeszoon DPM, FACFAS, FACFAOM³

The Foot and Ankle Online Journal 11 (2): 4

The triple arthrodesis surgical approach typically involves two incisions placed laterally and medially to obtain access to the subtalar joint (STJ), talonavicular joint (TN), and the calcaneocuboid joint (CC).  Despite the wide use of the two-incision approach, the traditional approach for triple arthrodesis has been described with a single lateral incision from the tip of the fibula across the sinus tarsi to the talonavicular joint, documented historically by Ollier.  The operative technique is described, 14 patients met the inclusion criteria, with a mean age of 50 (range 16-68). The most common diagnosis was posterior tibial tendon dysfunction (PTTD) (71%). Two (14.2%) required revisional operations: one developed a metal allergy and required hardware removal with soft tissue debridement and skin grafting all after achieving bony healing (7.1%), one developed a rearfoot varus requiring a dwyer calcaneal osteotomy (7.1%).  The union rate of each joint was 100% in the STJ, 100% in the TN joint, and 92.9% in the CC joint at 6 months post-operatively. The retrospective mean VAS pain score pre-operatively was 83, while the post-operative score was 42. The mean preoperative Talonavicular angle, Meary’s angle and Calcaneal pitch angle were 4.2; 4.8 and 15.2 respectively. The Immediate post-operative angles of each angle were 2.5; 1.2 and 22.5 respectively. At six months follow up, these angles were 2.6; 1.2 and 18 respectively.  

Keywords: triple arthrodesis, single lateral incision, exposure, union

ISSN 1941-6806
doi: 10.3827/faoj.2018.1102.0004

1 – Attending Surgeon, Ankle & Foot Care Centers, Boardman, OH
2 – Foot and Ankle Surgical Fellow, University Hospitals Richmond Medical Center, Precision Orthopaedic Specialties, Inc, Chardon, OH
3 – Attending Surgeon and Fellowship Director, Precision Orthopaedic Specialties, Inc, Chardon, OH
* – Corresponding author: elizabeth.sanders014@gmail.com

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The triple arthrodesis is a widely accepted surgical method for treating complex rearfoot deformity and arthritis. The surgical approach typically involves two incisions placed laterally and medially in order to grant access to the subtalar joint (STJ), talonavicular joint (TN) and the calcaneocuboid joint (CC) [1]. Despite the wide use of the two-incision approach, the traditional approach for triple arthrodesis has been described with a single lateral incision from the tip of the fibula across the sinus tarsi to the talonavicular joint, documented historically by Ollier [2]. The triple arthrodesis is indicated in conditions such as post-traumatic arthritis, tarsal coalition, congenital deformities, neuromuscular deformities and end stage arthritis [3]. As the accepted gold standard for treating these problems, the procedure has since been modified and adapted in more recent years [4]. While adhering to the principles of fixation, modified approaches have been adapted which still allow for proper exposure and preparation of the joints. Appropriate alignment of the joints is paramount if a good result is to be achieved. The single incision approach has been described in literature from a single incision medial approach for triple arthrodesis and double arthrodesis with some success [5]. We hypothesized that correction would be able to be achieved and maintained through one lateral incision approach for triple arthrodesis. The aim of the retrospective study was to evaluate the complications and results of triple arthrodesis performed using a single lateral incision and to measure radiographic changes over a period of six months.

Methods  

Medical records were reviewed of all patients that underwent a triple arthrodesis with a single lateral incision, performed by one surgeon from January 2008 until February 2016.  Patients were excluded from the study if they had less than six months of follow up, if medical documentation was incomplete, and if external fixation was used during the initial surgery.  Data obtained retrospectively from chart review included patients’ age, gender, preoperative diagnosis, total surgical time, complications, and adjunctive surgeries that were performed. Pre- and postoperative radiographic measurements of talonavicular angle, Meary’s angle and calcaneal pitch angle were collected and calculated.  All surgeries were performed by one physician (MM). A preoperative and postoperative score for pain was obtained by VAS scale (Visual Analog Scale for Pain) via phone survey. Analysis was then conducted to calculate operative time.

Operative Technique

The patient is positioned on the operative table in the supine position with a pre-fashioned bump placed under the operative hip as deemed necessary.  A thigh tourniquet is placed. The single incision is then utilized from the distal portion of the fibula over the sinus tarsi to the base of the 4th metatarsal on the operative foot (Figure 1).   

Figure 1 Incision placement for the single lateral incision triple arthrodesis extending from just below the lateral malleolus extending across the sinus tarsi to the base of the 4th metatarsal.

Figure 2 Dissection and exposure for the single lateral incision for triple arthrodesis.

The sinus tarsi can be located by inserting a needle into the sinus tarsi prior to drawing out the incision.  At the distal most portion of the surgical approach, the extensor digitorum brevis is identified and split longitudinally to gain exposure to the calcaneocuboid joint.  Next, the interosseous ligament within the sinus tarsi is resected and any subcutaneous tissue is removed. Careful dissection is continued to level of the talonavicular joint, where a combination of elevators and positioning of the foot allows for release of capsular tissues (Figure 2).  Using curettes, round burr, and curved osteotomes; articular cartilage is carefully resection from the CC and ST joints.

Figure 3 Exposure of the talonavicular joint and subtalar joints visualized with a pin distractor through a single lateral incision.

Figure 4 Distraction and preparation of the calcaneocuboid joint with a pin distractor.

A cervical spine distractor is utilized to aid in preparation of these joints (Figures 3 and 4).  This process is then repeated to expose and prepare the TN joint, while carefully maintaining anatomical alignment of the joint.  The joints are then further prepared using a 2.0 mm drill bit to fenestrate each joint. Temporary fixation is utilized and permanent fixation is achieved with one or two 7.0 mm cannulated screws to fuse the STJ followed by two 5.5 mm screws to fuse the TN joint (Figure 5).  The CC joint is evaluated and fused using one or two staples.

Figure 5 Percutaneous fixation of the talonavicular joint.

Figure 6 Post-operative scars of two brothers, both with posterior facet tarsal coalitions, now status-post triple arthrodeses performed with the single lateral incision.

Closure is performed in layers.  A Jackson-Pratt drain is placed. The Silfverskiold test is performed after arthrodesis to evaluate the need for tendo-Achilles lengthening or gastrocnemius recession.  These procedures are performed concomitantly as deemed necessary by the surgeon.

Figure 7 Pre-operative and Post-operative films status-post triple arthrodesis through a single lateral incision.

The patient is placed into a posterior splint and Jones compression dressing for the first week after surgery.  At the first follow up visit at one week, the patient is placed into a below knee cast for three additional weeks.  At the fourth postoperative week, the cast is removed and the patient is placed into a removable walking boot. Over the course of week 5 and week 6, gradual weight bearing is increased until the patient is fully weight bearing in the boot by the end of the sixth week (Figures 6 and 7).    

Results

14 patients met the inclusion criteria, 5 males (35.7%) and 9 females (64.3%) with a mean age of 50 (range 16-68).  The average BMI of the group was 34.1(range 19.6-48.7). The most common diagnosis of the patients operated on in this study was posterior tibial tendon dysfunction (PTTD) (71%).  The mean operating time of the single incision triple arthrodesis was 90 minutes (range 60-135 minutes). Of the 14 patients included in this study, two (14.2%) required revisional operations.  One patient developed an unforeseen metal allergy and required hardware removal with soft tissue debridement and skin grafting all after achieving bony healing (7.1%). The other patient developed a postoperative rearfoot varus deformity and returned to the operating room for a dwyer calcaneal osteotomy (7.1%).  One patient (7.1%) developed a non-union of the CC joint which was asymptomatic. The union rate of each joint was 100% in the STJ, 100% in the TN joint, and 92.9% in the CC joint at 6 months post-operatively. The retrospective mean VAS pain score pre-operatively was 83, while the post-operative score was 42. The mean preoperative Talonavicular angle, Meary’s angle and Calcaneal pitch angle were 4.2; 4.8 and 15.2 respectively.  The Immediate post-operative angles of each angle were 2.5; 1.2 and 22.5 respectively. At six months follow up, these angles were 2.6; 1.2 and 18 respectively. After analysis using the unpaired t-test, the P-values were demonstrated in table 4. Values of less than 5% (p < 0.05) were considered statistically significant. All surgical corrections as measured with the three angles listed were found to be statistically significant in the immediate post-operative period.  At 6-months follow up, the only measurement that was found to not be statistically significant was the calcaneal pitch angle correction.

Analysis and Discussion

Triple arthrodesis incision planning has been described very seldom in literature.  In the study by Moore in 2014, a comparison was made between two groups of patients in which triple arthrodesis was attempted via one incision vs two [6]. The study showed that while there may not have been statistically significant differences between the two groups in regard to union rates; a similar result could be achieved in a more efficient amount of operating time.  They also proved that the TN joint could be accessed and prepared properly through a lateral incision.

In a study by Bono and Jacobs  evaluating triple arthrodesis performed through one lateral incision, the union rate of each joint was 80% in the STJ, 90% in the CC joint and merely 38% in the TN joint [7]. The authors of this study concluded that a triple arthrodesis could not be effectively achieved through one lateral incision.  

Despite the dependable and reproducible nature of arthrodesis, the disruption of soft tissue and ligamentous stability of the bones has been shown to cause complications.  These complications include wound dehiscence, delayed union, nonunion, re-operation and operating time. These complications as well as the benefits of decreased operating times were well described by Weinraub in their study in 2010 [4].  The study also took into consideration the addition of the fiscal benefits of decreasing cost by decreasing operating time. Similar complications were also found in our study as demonstrated by our complication rate. The comparisons of our study, while the focus is on radiographic measurements and patient satisfaction scores, help to build on these previous studies by producing repeatable and measurable results through the single incision.   

While joint preparation and visualization can prove to be more arduous from a lateral incision, this approach has been demonstrated in the past to be successful.  Limiting the amount of surgical incisions that need to heal can help to improve time of recovery in patients that may have poor soft tissue envelope. Despite the lack of some assessment on clinical outcomes, the radiographic data that was obtained by this study demonstrated that surgical correction can be made and maintained by using one lateral incision for triple arthrodesis.

The limitations of the case study were its retrospective and non-randomized nature.  There was also no control group for comparison. While the data collected centered around radiographic measurements and patient VAS scores as a representation of the outcome, there was a lack of clinical assessment of a valid outcome in the study.  The study was also limited by the lack of a long term follow up group for measurement and comparison of data. Potential considerations for future research include a comparison group of single incision vs. double incision patients of similar demographics.  

Patient	Age	Sex	Diagnosis	BMI	Smoker	PMH	Complication
1	39	M	PTTD	31.6	N	HLD	None
2	49	F	PTTD	47	0.5 ppd	CA	Metal allergy I&D, HWR
3	54	F	Post-traumatic	35.4	N	HLD, Asthma, Hypothyroid	None
4	55	M	PTTD	29.5	N	None	None
5	52	F	PTTD	28.7	1 ppd	Hypothyroid	None
6	55	M	Post-traumatic	21.8	N	Depression	None
7	23	M	Spastic / Neurologic	19.6	N	CVA	None
8	68	F	PTTD	41.5	N	CA	Non-union CC joint
9	68	F	PTTD (Right)	37.6	N	HTN, HLD	None
10	68	F	PTTD (Left)	37.6	N	None	None
11	16	M	Midfoot Arthritis	24.3	N	None	None
12	53	F	PTTD	42.1	N	None	None
13	43	F	PTTD	48.7	N	HTN, HLD	HWR, dwyer osteotomy
14	56	F	PTTD	32.4	N	None	None

Table 1 Patient Demographics  (N=14 operations in 13 patients). Abbreviations: BMI: Body mass index; PMH: Past medical history; PTTD: posterior tibial tendon dysfunction; ppd: Packs per day; HLD: hyperlipidemia; CA: Cancer; CVA: Cerebrovascular accident, I and D: Incision and Drainage; HWR: Hardware removal.

Average Age	Gender	Diagnosis	BMI	Smoker	PMHx	Complications
50 (16-68)	5 Males (35.7%)	10 PTTD 71.4%)	34.1 (19.6-48.7)	2/14 (14%)	as summarized above	3/14 (21.4%)
	9 Females (64.3%)	3 arthritis (21.4%)
		1 neurologic (7.1%)

Table 2 Demographic summary.

Patient	Pre-operative			Immediate Post-operative			Follow-Up
	A	B	C	A	B	C	A	B	C
1	7	8	11	0	1	18	0	2	14
2	5	2	18	8	0	28	2	0	23
3	2	10	24	5	1	28	3	0	20
4	7	3	10	2	0	26	2	0	22
5	4	5	12	2	1	25	3	1	22
6	2	7	5	0	2	10	2	4	8
7	3	5	36	2	4	30	4	3	30
8	5	1	26	2	0	34	4	0	28
9	5	7	6	4	5	12	4	4	10
10	6	8	0	2	2	16	2	2	14
11	4	4	0	2	1	16	3	1	10
12	6	2	20	2	0	22	4	1	18
13	2	4	22	2	0	20	2	0	18
14	2	1	24	2	0	30	2	0	28

Table 3 Summary of Radiographic Measurements (Degrees). A: Talonavicular angle, B: Meary’s Angle, C: Calcaneal Pitch Angle.

Measurement	Immediate Post-op	Six Months Post-op
TN Angle	0.02	0.0092
Meary’s Angle	0.0004	0.0004
Calcaneal Pitch Angle	0.0475	0.2978

Table 4 Summary of P-values Post Operatively.

References

1. Myerson MS.  Triple Arthrodesis.  Reconstructive Foot and Ankle Surgery, Ed 2.  Edited by MS Myerson, Elsevier Saunders, Philadelphia, 2011.  
2. McGlamry D, Ruch J, Mahan K, Napoli D.  Triple Arthrodesis. Podiatry Institute Update.  1987. Ch 30.
3. Geocker RM, Ruch JA.  Triple arthrodesis. In McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, Ed 3.  Edited by AS Banks, MS Downey, DE Martin, SJ Miller, Lippincott Williams and Wilkins, Philadelphia, 2001.
4. Weinraub GM, Schuberth JM, Leem, Rush S, Ford L, Neufield J, Yu J.  Isolated medial incisional approach to subtalar and talonavicular arthrodesis.  J Foot and Ankle Surg 2010; Vol. 49: 236-330.
5. Jeng C, MD, Tankson C., Myerson, MD. The Single Medial Approach to Triple Arthrodesis: A Cadaveric Study.  Foot & Ankle Int 2006. Vol 27 (12).
6. Blake E. Moore, MD, Nathaniel C. Wingert, MD, Kaan S. Irgit, MD,  Christian J. Gaffney, MD, and Gerard J. Cush, MD. Single-Incision Lateral Approach for Triple Arthrodesis.  Foot & Ankle Int 2014. Vol. 35: 896 –902.
7. Bono JV, Jacobs RL. Triple arthrodesis through a single lateral approach: a cadaveric experiment. Foot Ankle. 1992. Vol. 13: 408-412.
8. Berlet G, Hyer C, Scott R, Galli M.  Medial Double arthrodesis with lateral column sparing arthrodiastasis: A radiographic and medical record review.  J Foot and Ankle Surg 2015. Vol. 54: 441-444.
9. Sammarco VJ, Magur EG, Sammarco GJ, Bagwe MR.  Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment.  Foot and Ankle Int. 2006. Vol. 27: 661-666.