1. Operative Care Stage 3 and
4 PTTD
Selene G. Parekh, MD, MBA
Associate Professor of Surgery
Partner, North Carolina Orthopaedic Clinic
Department of Orthopaedic Surgery
Adjunct Faculty Fuqua Business School
Duke University
Durham, NC
919.471.9622
http://seleneparekhmd.com
Twitter: @seleneparekhmd
3. Introduction
• Triple arthrodesis
• Fusion of the three hindfoot articulations
• Subtalar or talocalcaneal
• Talonavicular
• Calcaneocuboid joints.
• Responsible for
• Supination and pronation of the foot;
4. Indications
• Goal
• Achieve a stable, painless, and plantigrade foot.
• When possible, a procedure that preserves normal
hindfoot motion and mechanics should be
considered.
• In instances where this would be inappropriate
• Triple arthrodesis valuable salvage procedure.
15. Preoperative Evaluation
• All patients should have adequate circulation.
• If pedal pulses are not palpable
• Arterial Doppler evaluation for ankle brachial
indices, dorsalis pedis indices and normal wave
forms should be performed.
16. Preoperative Evaluation
• Sensation should be documented preoperatively
• The presence of peripheral neuropathy must be
identified to avoid potential complications of
postoperative Charcot arthropathy.
17. Preoperative Evaluation
• A complete understanding of the relationship
between the forefoot and hindfoot in supination and
pronation deformities of the foot is essential for
proper positioning of triple arthrodesis.
18. Preoperative Evaluation
• Pes planus deformity - a pronated foot
• Heel in valgus
• Forefoot is both abducted at TN jt and in varus
• Proper positioning of the foot at surgery
• Heel - five degrees of residual valgus
• Forefoot abduction - bringing the navicular
medially cover the head of the talus
• Can be assessed by palpation of the medial
side of the foot at the talonavicular joint to
identify any residual subluxation.
19. Preoperative Evaluation
• Long standing pes planus deformities
• Secondary contracture of the GSC
• Assessed by reducing the talonavicular
joint to neutral and then dorsiflexing the
ankle
• If contracture present
• TAL
• Recession
20. Preoperative Evaluation
• Valgus angulation of talus in the ankle
mortise suggestive of deltoid ligament
insufficiency
• May promote degenerative arthritic
changes in the ankle joint following triple
arthrodesis secondary to increased load
on the lateral portion of the joint.
23. Surgical Technique
• Multiple techniques
• Basic principles
• Surgical incisions placed to avoid injury
to the sensory nerves of the dorsum of
the foot
• Anatomic realignment
• Hindfoot to 3-5 degrees of residual
heel valgus
• Neutral alignment of the forefoot
24. Surgical Technique
• Preparing joint surfaces
• Remove all the residual cartilage and
subchondral bone to the level of exposed
cancellous surfaces
• Rigid fixation with compression of the joint
surfaces
• Maintain corrected position
• Promote fusion
• Bone graft needed if significant bony defect
26. Lateral Incision
• Final peroneals and trace distally to CC jt
• Elevate extensors of anterior process
• Enter subtalar and CC jts
• Prepare joints
30. Position
• Take the heel out of valgus
• Pin from neck to calcaneus
• Place hardware
• Reduce TN joint
• Correct abduction and supination
• Place hardware
• Place hardware over CC joint
31. Stage 4
• Ankle arthritis
• Ankle fusion
• At same time
• Pantalar fusion with TTC rod
33. Post-operative Management
• NWB in a compressive dressing with plaster splints
• 10-14 days
• NWB in SLC 2-4 wks
• X-rays at six weeks demonstrate adequate bony
healing, immobilize in a walking cast/boot for an
additional eight to ten weeks
• Immobilization is continued until there is radiographic
evidence of solid union with consolidation of the fusion
sites
34. Complications
• Malalignment
• Significantly increase the forces on the ankle
joint
• Excessive hindfoot valgus
• Increase the stress on the deltoid ligament
by as much as 76% increasing force
across the ankle joint
• May lead to continued lateral subfibular
impingement and continued lateral pain
36. Complications
• Residual hindfoot varus
• Cause overload of the lateral column of the foot
causing pain at the cuboid or base of the fifth
metatarsal
• Lead to lateral ankle instability and secondary
ankle arthritis
37. Complications
• Significant residual varus or valgus of the
forefoot
• Abnormal gait pattern
• Cause excessive forces across the ankle
joint
• May require revision of the triple arthrodesis
• Extensive calcaneal varus or valgus of the
calcaneus
• Corrected by utilizing a Dwyer type calcaneal
osteotomy
38. Complications
• Loss of motion remains a problem
• Produces secondary arthrosis of the ankle and tarso-
metatarsal joints over time
• These changes are often not apparent clinically
• Radiographic changes have been reported in over
fifty percent of patients
• This problem remains unsolved and the long term
implications unclear
39. Complications
• Nerve injury or entrapment of the sural nerve at the
lateral incision
• Require a neurolysis or nerve resection if the
symptoms become severe
40. Complications
• Failure to address an Achilles Tendon contraction
• Lead to excessive midfoot stresses
• Lengthened to achieve no more than 10 degrees
of dorsiflexion
41. Complications
• Secondary degenerative arthritis of the ankle
and midfoot reported 14-20%
• More common with residual malalignment
• Ankle symptoms can often be treated with the
use (MAFO)
• Midfoot pain can be treated with a UCBL
• If bracing unsuccessful
• Consider fusion/replacement of these
effected joints
42. Complications
• Avascular necrosis of the talus reported
• If present and symptomatic
• Initial treatment employ bracing
• Unsuccessful then consideration of ankle fusion
43. Complications
• If a triple arthrodesis is being done as a stage
procedure for a later total ankle or as part of a pan-
talar arthritis then a limited subtalar fusion should be
considered
• Only the posterior facet should be approached
• Do not violate the arterial supply of the talus from the
inferior neck
44. Complications
• Nonunions occur
• TN joint
• Theorized to stem from inadequate
exposure and preparation of the joint
surfaces
• If nonunion is asymptomatic no treatment is
required
• If nonunion produces symptoms then
revision of the nonunion with internal fixation
and bone grafting is generally effective
