This seminar mainly useful for all post graduates of orthopeadics and helpful for theory and practical examination.

1. Triple Arthrodesis
Dr Chirag Patel
Department of Orthopaedics
St Stephen’s Hospital

2. Introduction
 The most effective 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 Ryerson first 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 most common 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 obtain stable 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, triple arthrodesis 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 traumatic arthrits
 Degenerative arthritis
 Ctev
 Polio
 Ra
 Pes cavus
 Pes planovalgus deformity
 Cp
 Tarsal coalition
 Muscular dystrophy
 Charcot’s arthropathy

8. Contraindication
 Young child less 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
 A paper 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
 In talipes 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
 In talipes 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 APPROACH TO
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 is to 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 the inferior 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 classical triple
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 removal of 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 can be 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
 The Lambrinudi 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.  . In the 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 good result 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 the foot 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 the peroneal 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 wedge the 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
 The cast 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 for varus
deformity

30. Triple arthrodesis for valgus
deformity

31. Pes cavus
 Calceneocavovarus or 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 of triple
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 kite method
 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 in CTEV
 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
TN joints 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
At risk 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. Thank you