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Single Medial Approach for Triple Arthrodesis


Indications

  • Symptomatic adult rigid flatfoot deformity due to dysfunction of the posterior tibial tendon (stage III according to the classification of Johnson and Storm), which is not responding to conservative treatment

  • Tarsal coalitions

  • Inflammatory or posttraumatic arthritis of the hindfoot

Indications Pitfalls

  • Any kind of infection of the foot is an absolute contraindication for a hindfoot fusion.

  • Posterior tibial tendon-dysfunction stage IV with tilt in the tibiotalar joint with/without arthritic joint deformity comes with a higher risk for failure and progressive deformity.

Indications Controversies

  • Talonavicular and subtalar fusion is sufficient if the calcaneocuboid joint (CC-Joint) is not involved in the degenerative progress. This is to prevent wound complications on the lateral side and minimize risk of degeneration of adjacent joints.

  • Traditional triple arthrodesis is indicated in case of CC-Joint degeneration and if treatment of the sequelae of paralytic disease is necessary.

  • Cavovarus/varus feet are easier to correct through the traditional lateral dual incision technique.

Examination/Imaging

Clinical Examination

  • Trophic status of the foot and skin condition including vascular status

  • Remaining flexibility in the hindfoot and midfoot

  • Muscular strength and/or shortening (particularly the Achilles tendon)

Plain Radiographs (Weight-Bearing)

  • Bilateral anteroposterior ( Fig. 45.1A ) and lateral ( Fig. 45.1B ) views of the foot, in addition to mortise view of the ankle ( Fig. 45.2 ) and a Saltzman view

    FIG. 45.1

    FIG. 45.2

  • Evaluation of the talocalcaneal, talometatarsal, and talonavicular angles

  • Additional deformities of the midfoot and forefoot

  • Assessment of the degree of joint degeneration and bone density

  • Computed tomography (CT)-scan or magnetic resonance imaging is rarely needed in decision making but might help in assessing avascular necrosis (AVN), particularly of the talar body.

    • Weight-bearing CT scans may help in better understanding of complex hindfoot deformities.

    • Single-photon emission CT may help to assess the arthritic changes of the involved joints.

Treatment Options

  • Conservative treatment consists of orthotics and footwear modifications, which can be used to relieve pain if surgical correction is not possible.

  • In the case of involvement of the tibiotalar joint (valgus arthritis of the ankle joint), additional total ankle joint replacement or inclusion of the ankle into the fusion should be considered.

  • No true surgical alternatives exist for treating a painful rigid adult flatfoot.

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