Results of triple arthrodesis: effect of primary etiology

Double hindfoot arthrodesis using a single-incision medial approach in the correction of adult-acquired flatfoot deformity: a case series

BACKGROUND

Hindfoot arthrodesis is used in patients with advanced-stage acquired flatfoot, usually associated with degenerative joint disease. The objective of the present study was to evaluate the clinical and radiographic results of hindfoot arthrodesis using the single-incision medial approach.

METHODS

A case series of 18 consecutive patients undergoing surgical correction between 2015 and 2018 with hindfoot arthrodesis using the medial approach was evaluated. The clinical assessment used the visual analog pain scale, AOFAS hindfoot score, SF-36, and foot function index. Radiographs and personal satisfaction criteria were also analyzed.

RESULTS

All radiographic parameters evaluated showed a significant improvement (p < .05), except the calcaneal pitch. Pain decreased by 5.1 points (p < .001), and the mean final AOFAS score was 72.6. In three feet, a new surgery was required. Two feet developed talar necrosis. None of the cases presented surgical wound dehiscence, and two presented with superficial infection, which was resolved with the use of oral antibiotics.

CONCLUSION

Double arthrodesis (subtalar and talonavicular) to correct adult-acquired valgus flatfoot using a medial approach has a low risk of soft tissue complications and presents satisfactory functional results. Avascular necrosis is a serious complication that was present in 11% of cases.

Plantar Partial Pressure Analysis in a Patient with Reverse Extensor Digitorum Brevis Flap for the Treatment of Hallux Injury

Introduction

An extensor digitorum brevis (EDB) flap can be used to cover a small soft-tissue defect and has been widely used as pedicled flap to cover defects around the ankle and foot. However, its post-operative functional recovery is unknown. Few reports have evaluated gait after foot flap surgeries, although gait assessment is considered to be necessary for functional evaluation after foot reconstruction. We performed a reverse EDB flap to treat a right hallux injury and conducted a plantar partial pressure (PPP) analysis as a postoperative functional evaluation.

Case Report

A 30-year-old laborer suffered an injury resulting in necrosis of the distal phalanx and soft-tissue defect of the proximal phalanx. After amputation, the proximal phalanx was covered with a reverse EDB flap. PPP analysis involved a 4-m-long platform system (P-Walk) and was conducted 3- and 12-month post-surgery. Walking velocity and the single-support phase on the affected limb had increased markedly after 12 months. After 12 months, the PPP of the first metatarsal head was greater than on the unaffected side, and the cadence and single-leg support rate were equal to the unaffected side.

Conclusion

A nearly normal gait was obtained by covering the basal part of the hallux with an EDB flap and preserving the metatarsophalangeal joint.

Triple Arthrodesis for Adult-Acquired Flatfoot Deformity

Originally described as a means to address fixed deformities or uncontrolled movement of the hindfoot observed in paralytic foot deformities, triple arthrodesis has evolved into a powerful procedure for the correction of a variety of foot deformities. Over the past decade, multiple advances have been made with respect to diagnostic imaging, fixation options, bone graft substitutes, and postoperative regimens. While this operation requires experience and skill to execute, when properly performed, it allows for correction of deformity and a plantigrade and ideally pain-free foot for ambulation. The purpose of this review is to highlight advances in the procedure and its application to the rigid planovalgus foot.

Level of Evidence:

Level V, review.

Mid- to long-term outcome of 96 corrective hindfoot fusions in 84 patients with rigid flatfoot deformity

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction. The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus. A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively. In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10). In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique.

Management of the rigid arthritic flatfoot in adults: triple arthrodesis

The traditional surgical treatment for adults with a rigid, arthritic flatfoot is a dual-incision triple arthrodesis. Over time, this procedure has proved to be reliable and reproducible in obtaining successful deformity correction through fusion and good clinical results. However, the traditional dual-incision triple arthrodesis is not without shortcomings. Early complications include lateral wound problems, malunion, and nonunion. Long-term follow-up of patients after a triple arthrodesis has shown that many develop adjacent joint arthritis at the ankle or midfoot. This particular problem should be considered an expected consequence, rather than a failure of the procedure. Although the indications for and surgical techniques used in triple arthrodesis have evolved and improved with time (predictably improving results in the intermediate term), the triple arthrodesis should be regarded as a salvage procedure. Certain measures can be taken by the surgeon to avoid some problems. If patients are at risk for lateral wound complications, the arthrodesis could be performed through a single medial incision. However, this can make some aspects of the CC fusion more difficult. Implants would have to be inserted percutaneously, which prevents the surgeon from using either staples or plates. If a patient were to need a lateral column lengthening through a CC distraction fusion, this would not be possible medially. If either the ST or CC joints have minimal degenerative changes, they could be spared through a double or modified double arthrodesis, respectively. Although these procedures that deviate from the traditional triple arthrodesis offer promise, further study is required to better define their role in treatment of the rigid, arthritic AAFD. Triple arthrodesis is, by no means, a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of hindfoot positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to anticipate postoperative problems and provide modifications in traditional technique for certain patients.

Safety and efficacy of talonavicular arthroscopy in arthroscopic triple arthrodesis. A cadaveric study

This is a cadaveric study on the safety and efficacy of talonavicular arthroscopy in arthroscopic triple arthrodesis. Talonavicular arthroscopy was performed in 18 feet of 9 fresh frozen cadavers. The specimens were divided into 3 groups (6 feet in each group). The articular cartilage of the talar and navicular facet was abraded with a hemostat through the dorsolateral portal in group 1 specimens. The cartilage was abraded through the dorsomedial portal in group 2 specimens and through the medial portal in group 3 specimens. The area of cartilage abrasion represented the working area of the corresponding portal. The working area of individual portal and the relationship of individual portal to the adjacent neurovascular structure were studied. The medial portal averaged 12 mm medial to the long saphenous vein and saphenous nerve. The dorsomedial portal was 1 mm lateral to the intermediate cutaneous branch of superficial peroneal nerve and 5 mm lateral to the extensor hallucis longus tendon. It was 4 mm lateral to the deep peroneal nerve. The dorsolateral portal was 4 mm medial to the lateral branch of superficial peroneal nerve. In group 1, the working area of the dorsolateral portal averaged 60 +/- 4% for the talar facet and 66 +/- 12% for the navicular facet. In group 2, the working area of the dorsomedial portal averaged 56 +/- 3% for the talar facet and 64 +/- 8% for the navicular facet. In group 3, the working area of the medial portal averaged 40 +/- 4% for the talar facet and 55 +/- 11% for the navicular facet. Most of the talar and navicular surfaces can be prepared for fusion without the need of excessive bone removal during arthroscopic triple arthrodesis. This study confirmed the efficacy of the arthroscopic triple arthrodesis and arouses the surgeon about the risk of neural damage especially at the dorsomedial portal.