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Michael Troiano, DPM
Center for Foot and Ankle Disorders
University of Pennsylvania - Penn Wound Care
Adjunct Clinical Professor, TUSPM
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Michael Troiano Dr. Michael Troiano has disclosed that he has a financial relationship with HealthPoint
Male Speaker: Okay, rearfoot arthrodesis. This is a discussion that Dr. Kalish was going to have, triple. I kind of modified this a little bit just to satisfy our purposes for today. Obviously, rearfoot arthrodesis could be a day-long topic in itself. We’re not going to go through all of the indications or what have you, but very quickly, things that will be pertinent for your boards, things that will be pertinent for your long-term education patient outcome. Indications for triple arthrodesis. Triple arthrodesis is an endstage procedure. You should not be doing a triple arthrodesis unless this patient has failed everything else, including conservative therapy such as bracing or what have you. You absolutely don’t want to employ a triple arthrodesis unless this person has not responded to an Arizona brace or what have you. If the patient says to you, “I know I’m never going to wear an Arizona brace or a patellar weightbearing brace or what have you, I don’t want it,” then that’s fine. But, you owe it that person to give it a shot. Realistically, people do well with them. Bracing is its own little niche. There's a lot of people that don’t do surgery and they have great results with bracing. Once you get into the triple arthrodesis, you can’t go back. There’s a substantial risk for nonunion, wound dehiscence, hardware failure. There’s a lot that can happen, DVT because the person is immobilized for too long. You said, “Okay, well, we’re going to put him on Xarelto.” Realistically, that also is going to compromise wound healing because the blood is thin. Realistically, this is the last salvage procedure that you should perform with the understanding that you can handle any complication that exists. I certainly don’t mean to scare you, but these are the patients that keep you up overnight. It’s a lot easier when you’re attending this patient, and you go to bed, you don’t think about it. But I guarantee you that attending, just wondering, did they fuse the subtalar joint, is the talonavicular joint okay, what have you. Indications, painful joint secondary to arthrosis, posttraumatic arthritis, DJD, rheumatoid arthritis, and tarsal coalitions. We saw a lecture on the first day about rheumatoid arthritis. Rheumatoid is a major, major indication for triple. The gold salts of these people are on their anti-immune system drugs that they’re on, realistically, will also impede healing and fracture healing. We need to be very, very careful about our wound healing and fracture healing with the RA patients. Let’s get with their rheumatologist and see if they can stop these medicines for a little while, like the Inderal or what have you. Can we stop the corticosteroids for a while, because that’s going to be essential to your long-term success with the fusion. Chronic instability, Charcot-Marie-Tooth, ankle instability. If somebody has recurrent ankle sprains, that joint, that subtalar joint as we heard in the last lecture, can be negatively impacted to create posttraumatic arthritis, and then you’re looking at a fusion. Posterior tibial tendon dysfunction, this is our Johnson and Strom classification step 4. We’re looking at triple arthrodesis. Around step 2 or 3, you’ve got to be considering subtalar joint fusion or talonavicular joint fusions as possible long-term success. Step 1, we can debride the tendon a little bit, repair it, and they’re good to go. If biomechanics, as Dr. Schoenhaus pointed out yesterday, caused the problem, likely they will continue to initiate the problem even after you perform your surgical intervention. We need to really get to the root. Deformity, uncorrected congenital clubfoot usually in adults, the subtalar joint will kind of be endstage and you have to consider triple arthrodesis or subtalar arthrodesis, Charcot neuropathy, and talipes equinovarus. Limitations, it is a technically demanding procedure. In residency, you have lots of hands in there, there’s you, the attending, the junior resident, what have you. When you’re out in practice alone, if you’re not working with a resident and you’re not doing a ton of these, they’d become overwhelming. Your surgical scrub tech has no idea what he or she is doing. It’s time in the OR, people are being replaced by lunch shifts or what have you. It can be a three, four-hour case. You really want to have a strong support system before you engage in surgical intervention with this type of procedure. There is a slow recovery. I usually tell my patients at three months, 12 weeks, you’ll be 60 to 70% better. Six months, you’ll be 80% better. It will be one year before you’re as good you’re going to get. I never tell them before you’re as good as new, but as good you’re going to get. You don’t want to pigeonhole yourself into guaranteeing your patient a successful outcome with this, because all you’re trying to do is reduce their pain. If they’re in 10 out of 10 pain and you bring them down to 3, then you get a Christmas card. If they’re in 2 out of 10 pain and you nick a nerve or create a nonunion and bring them up to 3 or 4, you get yourself a lawsuit.
Let’s think about that before we come in with gun blazing performing procedures. Triple arthrodesis or fusion should not be used when soft tissue procedures are left, lesser arthrodesis would correct the problem. Goals, correct, resist and relieve pain. You want to correct the cavus or planus deformity, resist the muscular imbalance, and relieve the pain of arthritic joints. All you want is a plantigrade foot. This person is probably never going to be a marathon runner again. You have to let them know that, alright? Some people do function just fine and they go back to working on their scaffolds high up in the air or running marathons, but that’s few and far between. Ryerson, early 1900s, described the triple arthrodesis as a talectomy with tendon transfers, but varus and valgus deformities of the hindfoot occurred. Polio patients ambulated better with artificial limbs. Most of these people were not cast. They were not fixated at that point. They were just cast to mobilization. Davis is known as the father of horizontal sectioning of the foot. A curette or an osteotome was used through the STJ, continuing through the talar head and navicular. Surfaces were curetted and bone chips were left as an in situ graft. Obviously, with the use and [indecipherable] [06:20] of our technologies, infusions have become more predictable. At the same time, we still get back to the simple joint preparation that they used, saws, air impact osteotomes, curettes, what have you, osteotome in particular. There’s no real great way to prepare the graft that’s easy and fast that doesn’t cause osteonecrosis. Davis, again, had the idea of the double arthrodesis, fusion of both the TC and TN joints, corrected the varus and valgus, and adduction, abduction component. We had Ryerson who expanded on Davis’ work and proposed fusing the CC and tarsometatarsal joints as well. Ryerson, not Davis, historically is often falsely credited with the modern concept of the triple arthrodesis. Realistically, it’s probably Davis who coined the procedure. The goals, again, are to obtain adequate exposure, hemostasis and using atraumatic technique, the primary tenants of AO that we discussed a couple of days ago. You don’t want to do a ton of dissection here. When we create tons and tons of layers, what we’re doing is we’re devascularizing the skin and we’re guaranteeing ourselves a wound dehiscence. We want to identify the deep fascia, separate the superficial fascia from the deep, and then close as quickly and as easily as possible. There are a couple of incisions which are accepted. The Ollier incision is what many people use, which is the bottom left incision which we see. It is a transverse incision from the tip of the fibular malleolus across the sinus tarsali to the TN joint dorsally. Disadvantages is you’re going to encounter and probably cut or entrap every single nerve on the lateral side of the foot. These patients have to be aware that they will, guaranteed, have numbness and tingling which could be permanent after this surgery. You also encounter the extensor tendons and the peroneals through this incision. It’s not a favorite incision, but historically, it is an accepted incision. The two incisional approach is probably the most accepted approach at this point. You make a medial longitudinal incision between the anterior and posterior tibial tendons, beginning anteriorly to the tibia and extending across the TN joint to the NC joint. Again, there’s some issues with this incision such that the saphenous nerve is right there medially. The sural nerve is laterally. Again, you have to counsel your patient on the likelihood of nerve entrapment, number one. Number two, I don’t know that you exactly need to make the second incision. Certainly, in a very, very hyperpronated flatfoot, the second incision will help. It certainly allows you to denude the cartilage on the medial aspect of the talonavicular joint. At the same time, I think preferred way, my hands, is the one lateral incision. The lateral incision approach either uses an oblique sinus tarsal incision or longitudinal incision, beginning distal to the fibula and extending across the CC joint. It’s more of a calcaneal fracture AO type incision. You don’t make that 90-degree angle that you do and it’s above the angiosome that the calcaneal fracture is associated with. Therefore, the instance of healing is much, much more predictable. Again, Davis, as I eluded to before, recommended plaster casting. Ryerson used Chromic suture through the bone prior to casting. Patterson sutured the bones together after wound closure and cast application. We went from an absorbable screw to now external fixation, pins, plates, staples, screws, you name it, we now have it.
Again, it makes these procedures a little bit more predictable, but still nonetheless not something that you can feel comfortable with. External fixation, I am a big proponent of. This is the right medical Stealth frame that I actually love to use. Reason being is for the same AO principles that we discussed earlier. With a screw, you’re limited to the amount of compression that you can get. If you think stage one of bone healing is resorption of that interface, what you can do with external fixation is you could tighten after the fact and re-oppose those bony surfaces, almost increasing the rate of fusion by not increasing the compressibility but increasing the stability of that particular fracture fragment or arthrodesis fragment. I am a big proponent of external fixation for the triple arthrodesis. Plus, it’s a lot faster. It’s a lot easier. When you throw screws, there’s subtalar joint screws. There’s always a question of do you throw it from the calcaneus into the talus. If you do that, then the person’s walking on a screw head. On the other side of the coin, if you throw it from the talus into the calcaneus, you’re going from stable to unstable. Is that the best treatment? In other words, you’re grabbing the subtalar joint or the calcaneus towards the talus. Plus, if that screw head subsides a little too far, you crack the talus. If it backs out a little bit, that dorsiflexion of the ankle will hit the screw head and it will cause catastrophic damage posttraumatic arthritis to the ankle joint. Then, you’re looking at talonavicular screws, how many should you use, two, three, what have you. There becomes a big fixation issue with the triple arthrodesis. Again, in order to get good at them, you really have to do a lot. Certainly, you’ll find your own groove. But in my hands, I think, external fixation works the best. Surgical instruments, again, have your armamentarium lined up for you. The last thing you want when you do this case is to be waiting for nurses to be grabbing things for you. You really want a nice outlined tray, curettes, lamina spreader, so you can see these joints both smooth and tooth osteotomes. If your hospital has a MicroAire impact osteotome, it’s like a little osteotome on a hand piece. It’s a jackhammer. It takes off the cartilage very, very easy. People like burs, like a football bur. I’m not a huge fan of it. I think they call it because of mess and don’t really get down to subchondral bone. When they do, they kind of burn it, but it is acceptable. Periosteal elevators, Hohmann retractors, Crego elevators, and of course, multiple hands. You want people to be able to retract for you, people to be able to run a set. This is not a procedure that you want to do on your first day after graduating residency with a nurse that you never worked with before, just he or she. Preoperative x-rays, okay. We have to identify what we’re looking for. Why are we doing this fusion? Are we looking for an in situ fusion to take away pain? Are we trying to realign joints? This all has to be decided prior to our surgical intervention. Incisional approach that, again, we probably favor is this kind of lazy S lateral incision, one incision approach. It allows you to kind of go above the peroneals and retract them either dorsally or plantarly. It allows you to see the sinus tarsi. This hook here goes right up to the aspect of the lateral foot, so you can attain at TN joint from the lateral side a whole lot easier. Again, after you make your incision, you’re going to take your J stroke and retract and reflect the EDB muscle. Actually, take a large suture, like a nylon, number 0 Nylon and just suture through it and pull it back as part of my retraction. Flip it upward or dorsally. Now, you’re going to expose the calcaneal cuboid and talonavicular joints through this incision. You can see them at the top of your screen here. They kind of jump right out at you. After that, we’re going to go into the subtalar joint and we’re going to just use an osteotome to pry apart the capsular adhesions and capsule of each joint, so that each joint is reflected and identified. I want to move very quickly. Once we kind of pry apart the interosseous and the cervical ligaments with our osteotome, being careful not to slip and hit on the other side of the ankle, the FHL or the neurovascular bundle. Once the subtalar joint is exposed, we see our
well-exposed subtalar on the right, our calcaneal cuboid joint on the left, and the joints are ready to be prepared and fixated soon thereafter. Again, this is a MicroAire impact osteotome. If you have any abilities at your hospital, whatsoever, to order equipment, this is something that you want in your armamentarium. It is basically a jackhammer which will lift across the periosteum and the cartilage in the surfaces preparing nice bleeding subchondral bone. The subtalar joint is resected usually first. Reason being is when you resect the subtalar joint, you can affect the talonavicular joint and the calcaneal cuboid joint.
Although you don’t necessarily fixate the subtalar joint first, usually resect it first because it opens up the contralateral joints. Once the joints are prepared, you resect the CC joint and TN joints with a sagittal saw and you pin your Cyma line. You’re going to check everything under
C-arm. Once you’re comfortable, we’re going to move forward to fixation. There is kind of the head of the cuboid coming off, talus underneath. Now, you’re going to fit your joints together. They fit together like a little puzzle. You can use your bur or you can use your sagittal saw to reciprocally clean the joints, ensure that they hit against each other. This is a picture of a lamina spreader just doing the final calculations with the bur. Then, we’re going to fixate it provisionally with the K-wires. At this point, this is the stuff that makes you feel better, orthobiologics, right? There’s a million of them. Stryker has Vitoss and HydroSet. Wright Medical has PRO-DENSE and PRO-STIM. Every week, there’s a new product that comes out, which is osteoinductive or conductive or what have you. You really want to use those with inductive capabilities more than conductive capabilities, because those are the ones that will actually incite fusion. I like to take a lot of bone marrow from the tibial tuberosity and mix that up with things like Vitoss. It becomes a structural graft that fills in all your gaps, and at the same time, will incite bone healing. Here, I used two CLAW plates in the talonavicular and calcaneocuboid joint with a screw in the subtalar joint. This person had a failed evidence with basically arthrosis at the subtalar joint because the evidence graft subsided into the subtalar joint. Then, they also had posttraumatic arthrosis of the calcaneocuboid joint, so triple arthrodesis was indicated. There’s a lateral view of the patient with their prior failed evidence. Here is the triple arthrodesis with the Stealth that I discussed before. Again, these two pins coming across the midfoot will compress equally or independently, whichever you choose, by their particular cars. Another case is, obviously, a pretty significant flatfoot deformity with a large amount of valgus position, not only to the rearfoot but the ankle as well. In this case, you want to do your osteotomy to get the calcaneus back under. Osteotomy is done and then you realign the talonavicular joint. We have a plantigrade and rectus foot. There’s a lateral view. Again, we discussed this yesterday, but as residents for your boards and for the rest of your career, know this slide inside and out. This is very, very important. This is probably one of the biggest things that you should have gleaned from this weekend. When you fuse a subtalar joint, you take away 26% of the range of motion to the talonavicular joint, and 56% of the motion to the calcaneocuboid joint. You’re looking at 70% reduction in motion of the TN joint. Talonavicular infusion limits the subtalar joint range of motion to about 10%. You take away 90% of that subtalar joint motion by doing a TN fusion. Then, the calcaneal fusion, you see as well. I’m not going to belabor the points, but memorize this slide because if you have somebody with Johnson and Strom posterior tibial tendon dysfunction stage 2 or 3, you go ahead and perform your talonavicular fusion, you just as well did a triple to that patient. Every reaction is created as a consequence. That may be what you planned for. You said, “Hey listen, I want to disturb the subtalar joint motion. I want to lock it up.” On the other side of the coin, if you don’t have a great subtalar joint to begin with and you fuse the talonavicular joint, what you’re doing is you’re increasing the amount of arthritis to that joint, and therefore, you might as well go ahead and fuse the subtalar joint as well. We have to be cognizant of what we’re doing. There are times where a subtalar joint would be more indicated as a fusion in the talonavicular, talonavicular fusion more than the subtalar joint, what have you. Each patient is different. Again, rule of thumb, TN fusion locks up 90% of the subtalar fusion. Subtalar locks up 70 to 80% of the TN. Complications, malalignment of the hindfoot, increased forces at the ankle joint, excessive hindfoot valgus, residual hindfoot varus.
By doing a fusion, especially a non in situ fusion, you have to be prepared to perform other dynamic balancing acts, such that you can actually recreate this foot and unmask a varus condition to the forefoot, or you can unmask a metatarsus adductus. Be very cognizant that you have an exit plan or you’ve told this patient, “Hey listen, we’re going to have to stage this. We’re going to see what the rearfoot does. Then, once the forefoot determines itself based on the rearfoot fusion, we may have to address the forefoot later.” Malalignment of the forefoot, again, residual forefoot varus or valgus, nerve entrapment of the sural nerve or saphenous nerve occurs oftentimes. Untreated Achilles tendon contractures, be prepared to do a TAL. Make sure that is on the consent, because oftentimes you resect the joints enough and it puts some laxity on the Achilles. Other times, the equinus is still present, thus, precipitating the need for an Achilles tendon lengthening. AVN of the talus, nonunion, wound dehiscence, you really only get one good shot at a fusion. You really do. As a resident, it’s exciting to go do a nonunion repair, and you’re going to take grafts from the calcaneus. You’re going to have the orthopedist get the graft from the hip and, you know, where it’s a big procedure. But boy, you don’t want that headache when you get out. Do it right the first time and mitigate the chances of AVN or nonunion, because there are catastrophic consequences to deal with. It’s never the same. You get one good shot at a fusion. Pseudarthrosis, it is possible to have a painless nonunion. Interpretation of much of the literature is clouded by inclusion of many different techniques. Some of which involve substantial resection of bone, thus definitive conclusions of morbidity cannot be drawn. That’s a fancy way of saying, you read a lot of literature and they say, these people went on to a painless nonunion. That is not necessarily what you’re striving for but it does happen. Sometimes you get lucky. You want to make sure you document that the patient is having no pain. It’s a painless nonunion. You want to make sure that you’ve offered them other techniques. Great, if they have a painless nonunion. Far be it from you to look at an x-ray and say, “Wow, Mrs. Jones, you really should be in a lot of pain right now.” On the other side of the coin, you have to be cognizant when they’re happening and you have to document them. Operative pearls and incisional approach, best approach for exposure, well, minimizing soft tissue trauma. Anatomic dissection, I can’t stress that enough, anatomic dissection. Preserve the concavity or convexity of the joint. The talonavicular joint is a concave ball and socket joint. Don’t make it a convex joint. Don’t’ make it a flap joint, if you can avoid not to. Because you kind of want to play on the saddle or ball and socket joints that exist, such that the bones fit together a whole lot easier. It’s more like a puzzle piece that you’re not changing. Calcaneal position can be augmented for restoring a residual of 3 to 5 degrees of valgus. You want to 3 to 5 degrees of valgus, about 5 degrees of abduction to 15 degrees of abduction in the forefoot. You want the line of progression of that second metatarsal to line up with the tibial tuberosity, so that there doesn’t have to be a lot of ankle joint angular combination. Plus, you’re guaranteeing this person’s going to develop arthritis at the subsequent joints. Therefore, you want to be ready for an ankle replacement or fusion in the future. Plan every step, two steps ahead. Postoperative course, are they diabetic? Do they smoke? Nonweightbearing for 6 to 10 weeks at the least. Are you augmenting them with vitamin D? Is their nutrition adequate? Are they capable of healing? After that 6 to 10 weeks of non weightbearing, whether it be in a cast or CAM walker, you want physical therapy. I can tell you that I was involved in a pretty bad lawsuit. Again, this is a pearl whereby I did a triple arthrodesis on somebody with polio. I actually did a pantalar fusion on somebody with polio. First, I did the ankle and I went and did the triple arthrodesis. I sent them to physical therapy. Big outfit, NovaCare, okay. While they’re at physical therapy, they get to the tech and the physical therapy tech that happens to be a student can’t figure out why the forefoot won’t go upward. She keeps on jamming the talonavicular and calcaneocuboid joint, having my patient jump rope on her tippy toes, having my patient walk on an incline, having my patient do heel raises, can’t understand why this thing is not moving. Now, on the prescription, I put down “NB, nota bene, patient has pantalar fusion.” Nobody ever looked to see what that was. This particular outfit wasn’t familiar with that type of surgery, especially this physical therapy aid student. Eventually, she overcame my surgical fusion and she was able to break it up. Finally, the forefoot moved. The patient ends up suing physical therapy company because they had no idea what they were doing.
Be very cognizant, when you fuse someone, that that prescription says what the procedures that they have, and do not manipulate or what have you. In retrospect, I probably should have called as soon I saw the first report. These are your babies. These people are your babies. You want to take care of them going forward. Complications, nonunion is reported as high as 40%. Again, we need to have a stable stomach when doing these procedures, delayed union and malunion, infection, nerve entrapment, limb shortening, and incisional dehiscence. People with a triple arthrodesis, I think, everybody should get a rocker bottom as well to their shoe. It’s pretty inexpensive to add. It just helps the ankle not degenerate. It also helps with the limb shortening aspect. That’s it. Thank you. Get you out of here kind of early. Does anybody have any questions? Alright, good luck in the drawing.