Stanley R Kalish, DPM discusses the importance of Triple Arthrodesis, it’s indications, and common fixation modalities for this procedure. Dr Kalish also presents anatomic considerations when performing this type of surgery, as well as provides valuable insight into technique and case specific hardware selection. He closes with case presentations highlighting the concepts discussed in the lecture.
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Stanley Kalish Stanley R Kalish, DPM has disclosed that he receives Honorarium/Expenses, is a Consultant to and serves on the Speaker's Bureau for Pfizer and Merck. He will be speaking on the investigational products dalbavancin and telavancin.
TAPE STARTS – [00:00]
Stan Kalish: I'm Stan Kalish and I'm going to talk to you about Triple Arthrodesis. I don’t expect you to understand how to do triple arthrodesis unless you’re doing it. Proudly, podiatric physicians are the best in the world for this operation. At the institute where I founded it with a gentleman named Dalton McGlamry and John Ruch many years ago, we have done over 5,000 triple arthrodesis. And the operation is not without problems. And so the thought process for this lecture is not to teach you how to do it but to teach you what I’ve learned about it. So we’ll weigh this… when this… when am I supposed to start? Right now, guys? You want me to talk? You want me to wait a few minutes until you let me enter in. It’s up to you. You want me to talk? Yes? Okay.
I'll wait until a few… hey, Allen. Nice to see you. Yeah, that’s better. You’re not blinding me so much.
It’s a good operation as operations go. But if you don’t have to do it, don’t do it because everyone who’s had a triple arthrodesis is going to be out of commission for at least three months. If you have a problem, it could be two years.
So it is a stable operation. It’s predictable. It’s functional. And in my mind, no replacement exists. And proudly no matter what our orthopedic foot and ankle guys will tell you, we developed it. We were the first to do the three screw triple arthrodesis. We were trained in Davos before they knew what a podiatrist was. They had no idea what we were even doing there, the American orthopedic surgeons. The Swiss didn’t care. They saw we were interested in learning how to do AO.
So it’s a good operation. Don’t do it unless there’s joint pain, instability, and mainly neurological instability would be the most critical one, a failed prior procedure that falls into a large category of indications for the triple arthrodesis, progressive conditions, progressive neurological conditions and neuropathic conditions such as Charcot.
So Charcot is a big one but I want you to understand that Charcot presents with challenges both medically and surgically. My favorite quote over the years "is these patients are biologically bankrupt." And you see them from the womb to the tomb. They never go away. Every triple arthrodesis gets its nails cut by my staff every 8 to 10 weeks. They are in the VIP program. Nerve conduction and Doppler’s studies are done yearly on them. The triple arthrodesis is evaluated radiological yearly. We have a three dimensional CT scanner and [Indecipherable] [0:04:07], I am going to talk to you about that at 12 o'clock about three dimensional imaging for the foot and ankle. So the neuropathic Charcot foot is a big challenge but it’s also a big volume of the type of cases that need triple arthrodesis. And of course, the calcaneal fracture which occurs mainly in men who fall from heights of greater than six feet. It is one of the largest, if not the largest financially disabling Workman’s Compensation claims that exist as from the calcaneal fracture. All different degrees of it and all the classifications that exist that make this a very, very dangerous and painful disabling force.
The displace classifications are a frequent reason that triple arthrodesis are performed. Now you say, “Wait a minute, Dr. Kalish. You talked about fixing calcaneal fracture, Dr. Caldarella [phonetic] always talks about fixing calcaneal fractures.” Yes, they can be anatomically fixated but understand the complexity of the fracture was intra-articular and no matter what you do to put cartilage back together, it becomes arthritic to some degree. And when that happens, you say, “Well, why did I go and do an operation to try and stabilize the calcaneal fracture? Why didn’t I just do a triple arthrodesis?”
Well, sometimes ASIF, a fixation, an open reduction internal fixation works and the patient can function with anti-inflammatories and all the things we know. But what that also does for the future of triple arthrodesis is it creates a stable model to fuse, not a displaced model. Many calcaneal fractures go on to arthrodesis. As I said, open reduction and internal fixation ASIF will also make any triple easier as the reduction creates a better ultimate fusion position. Everybody got that? Okay.
So I’m not going to talk about calcaneal fracture because there’s so much to talk about in this operation, but let’s just say a typical 59-year-old guy who jumped off a tree from a height of four feet. What he was doing up in the tree is beyond my belief. My dear friend who spent 44 years as the best gastroenterologist in Atlanta was up on a ladder in his garage changing a light bulb, fell, broke his calcaneus and broke his neck and he is a quad. Men are stupid. They don’t belong up on ladders when they’re 60 years of age. Let someone else to do it who is a professional.
So I’m going to talk about weight bearing CT scanning. Now, obviously this is where regular CT scanning is okay. You’re not going to take an acute calcaneal fracture and take them out of their Jones compression or bring them primarily from the emergency room, “I want you to stand on this. I want to see how your foot’s pronating.” That’s non-sense. But what you want to see with the CT scan is a three-dimensional XYZ image, which we’ll talk about later, and see what you have to put back together and what you have to elevate and what you have to bone graft.
And we have such wonderful modalities I see out in the exhibit hall, locking plates and small wire frames. We have a lot of choices in how to fixate these fractures perfectly. Rule of thumb, don’t open it if you can’t fix it anatomically. It’s not going to be 100%, but don’t open it and get – and do a half-assed fixation, throw wires in their just to say you opened it. Anatomically open it, understand the corridors that you have to go into, the structures at risk. Get as much information about the fracture before you go into it.
One of the things that I’ll talk about later is three-dimensional rendered imaging or 3D CT scanning. Not particularly important in the acute calcaneal fracture but really important when that fracture heals for better or for worse and you’re considering doing a triple arthrodesis because not only do you get a rendered image but you get images on the axial plane, which is cutting the leg from the top to the bottom all the way to the calcaneus and then you are get in an additional sagittal image from medial to lateral and you get a coronal image. So these are really important in giving you information to get a 3D image in planning a triple arthrodesis.
And I’m going to talk for a good half of an hour or at 12 o’clock about weight bearing CT imaging, so I won’t waste a lot of time here.
But let’s talk about what you have to do when you get prepared to do any of these surgeries and be aware that bone is necessary – free stride bone is okay. Bone from the hip is ideal. Taking bone from the tibia is not such a good idea. What you need to do is understand your need to have the availability of any of these allogenic bone grafts substitutes so that you can fill the defect.
In calcaneal fractures when you create a negative Bohler tuber joint angle and drops down to 0 or below, when you elevate it with a big Sayre elevator, what do you wind up with? A big dead space because that bone is gossamer. It’s got to be filled in. You could fill it in with anything. Why? It’s very vascular. So it’s not like you’re dealing with something that doesn’t heal.
In these, we now have low-profile locking plates. I won’t spend a lot of time on locking plates, but they’re wonderful especially for the calcaneal fracture. And a conventional plate is too big, a locking plate actually can be low profile, it doesn’t have to be low profile. And the conventional plate may be less than optimum in this type of fractures, especially when you’re dealing with poor bone quality.
So if you’re planning a triple arthrodesis in a Charcot patient with poor bone quality then your thought process should be, what do I know about locking plates? And then how they are going to help here in patients who have osteopenia and poor quality bone? Where you can’t get cortex to cortex and good compression and you don’t want a big plate in there. I remember seeing a Tom Cane [phonetic], one of my great residents, one of his early calcaneal fractures and both sides to his because he used two traditional plates medial and laterally. I said, “Tom.” He said, “Yeah, I learned. That’s a bad lesson to learn.” I thought, you know, "I used two plates." But that was in the era pre-low profile plates. So when you have multiple fragments, locking plates are important.
Where is the external fixator fit into this series of operations? It’s a whole new learning curve and I use it for two purposes. You can do primary fixation like the Russians do with arch wire and I will tell you about that or you can use it as a backup and lure the cast especially in open wounds and in Charcot in the presence of ulcerations that you have to attend to while you are stabilizing the wound, so I do that.
I’m not going to talk a lot about locking plates, they act like a second cortex. It acts like an internal external fixator and that’s exactly what it does. It may not be needed in all cases of triple arthrodesis. The issue is simply this, what is the quality of bone and if you want arthrodesis to occur and you can feel or see you’ve got all the imaging preoperatively and you run wires across that site and those wires, boy, that went in easy, you know what it means to drill an osteotomy. The bone quality should be determined by the tactile discrimination of your fingers to your brain and when you see that that Kirschner wire or that Steinmann pin is going in easy, your thought process should say, "I’m going to have trouble compressing this because the bone is not good," okay? Locking plate.
So that’s what this is and we can give you separate lectures on that. But the locking plate attaches to the plate itself and actually is an internal, external fixated. It’s not up against the bone like a normal plate. Okay. It’s not sitting on that other cortex. So in studies done, the biomechanics locking plates, four times stronger than conventional plates, also four times more expensive. Okay. So now we have a conceptually know we’ve diagnosed this, we’ve got CT scans, we’ve got experience, we’ve got a patient who can tolerate a four-hour, three-hour, two-hour operation, we now have to say how do you approach this.
Traditionally, the orthopedic approach has been that Ollier incision and we’ve modified it at the institute in the 5,000, maybe more now triples that we’ve done there in 40 years. And again, the operation approach is dependent on the deformity. It’s going to be a little bit different in a flat foot than it is in the cavus foot. Charcot foot is going to be a little different as well the approach, the choice of fixation I just talked about and ancillary procedures to make sure that it works.
So we use a medial incision and a lateral incision. Structures at risk, obviously posterior medially, stay away from the posterior tibial nerve. You’re going to run into branches, the intermediate medial dorsal cutaneous nerve with lateral incisions and you’re going to run into the sural nerve. Retract it with a big rubber band retractor and be aware that it’s there. However, it’s a choice between doing the operation and cutting a small fiber of a nerve, cut the nerve.
And we’ll talk a little bit about internal fixation versus external fixation for triple arthrodesis. And obviously, external fixators have a learning curve and the Russians and their masters have taken me to the wall, but I’m a big boy, I can handle them and I use internal and external fixation concomitantly. My external fixator mainly in Charcot is not as primary as Dr. Weinstein does as a primary fixator or the Russians, but as a backup to what happens if that osteopenic bone doesn’t hold even a locking plate. I can still adjust an external frame and save a result.
So the difference between an internal fixators and external fixators is the skin. That’s all. Conceptualization is the same. Types of fixators we’re talking about circular fixators, we’re not talking about pumpkins on a stick, they’re different fixators. Unilateral fixators for fracture, for arthrodiastasis, et cetera. But internal fixation is also used and more frequently used in triple arthrodesis than external fixation. Incisional planning is a little bit different with external fixation. And here you see arched wires to get compression of the TN and the subtalar joint. And again, the approach is a little bit different. Wire placement is different. You have limited – you can get away with a limited amount of dissection in comparison to using plates and screws.
Safe medial corridors, SAR, structures at risk, watch them. You may run into cross branches of nerves and cross branches of vessels and veins. Just be aware of it. Don’t just tie off everything and wonder why your leg is so edematous postoperatively.
Unilateral fixators, not really, you know, have indications in triple arthrodesis. They’re used for other reasons but they’re available and they do have good indications for fracture stabilization spanning infected areas, joint distraction, arthrodiastasis, callus distraction that can be done unilateral. They come with electric motors that do it automatically, so – but not for triple. So we use smooth wire or Ilizarov type fixation. This is an Orthofix frame. But every good company out there has their own frame which works.
Save lateral corridors, sural nerve mainly is what you’re concerned about, peroneal tendons. And when you are planning this operation, if you’ve never done one, don’t do it. If you’ve only done it as a resident, ask your attendings to come in and help.
You know, if I was a resident in Dr. Schoenhaus' institution., I’d say, “Dr. Schoenhaus, what are you doing next Tuesday? Can you skip your golf game? I need help.” Because he’s done hundreds. Okay.
He may not take the knife from you, but he can guide you. And that’s what you need. And know, once you’ve done a few, you start to get your confidence and understand it. Most importantly, don’t go in there without the knowledge of preoperative planning. Because complications occur between the ears of the surgeon, not the bones of the feet. It just happens. Okay. And it’s your fault because you didn’t do something or you didn’t think about something. You didn’t plan something.
So the hardest person to blame in these surgeries is yourself. Joint resection is important. Medial and lateral incisions, don’t use blades that burn tissue, use sharp blades. Cool down the blades, take your saline, put it in the refrigerator. You’re not a general surgeon. You don’t need abdominal heat. You’re not going to drop the body temperature. You’re going to cool the blade down so the blade doesn’t burn the bone. Don’t cool the bone down. Cool the blade down so you don’t burn the bone.
Joint resection, and again, your choice of joint fixation dependent, number one, on the anatomy, the quality of the bone, your skill, your comfort level, whether you’re going to do an external fixation or an internal fixation. Here you see all the varieties and commutations. And here you see one of the early – and it’s ours. We invented it. It came out of our experience in the 70s in AO in Switzerland. We came back and did three screw triple arthrodesis. Only to hear beware the podiatric, the podiatrist, they’re stealing the foot. Of course, we’re stealing the foot. We’re better.
So fixation, the difference is where the axial force is applied, whether it’s internal or external fixation. And you can use it concomitantly. Because sometimes, you put screws and they move. They slip. So what do you do? You can’t put a screwdriver in the skin and tighten it. So what you do is you can apply an external frame.
So here you see the methods of compression for internal fixation either using large – the cancellous screws and I’ve seen some guys go from the bottom up. I don’t like to make a cut in the heel underneath the plantar fascia. I would like to come in dorsally, but it’s acceptable. And either 2 screws and the 4.0 screws in the TN and CC joint or 3, 6.5 screws or some of the new modified cannulated screws. There’s tons of stuff up there.
Archwire. You need to take and understand the archwire concept if you’re going to do triple arthrodesis with an Ilizarov frame. You’re using the wire to create compression, attaching it to the frame and tensioning the wire. And you have ankle wires and archwires, which will give you great compression. And this is what the Russians do. They don’t use internal fixation.
Joint fixation, followed by closed suction drainage. And again, meticulous handling of the tissues. Don’t beat up the tissues. You’re going to always have a problem.
Stable platform. The Ilizarov frame creates a very stable platform. And as I said in the Charcot foot, it allows you to concomitantly see an ulcer rather than deal through a windowed cast. Understanding you want it fixed in slight valgus, you know the famed Biblical terminology, ‘thou shall not varus’ and the slight valgus. And in women who want to get back into shoes, a little bit pumps and high heels, a little plantar flexion.
So I’m going to talk about – I could talk about 40 years, but I picked a bunch of cases and experience and 500-plus cases and over 42 years of doing this, you can hardly believe I’m that old. I look out in the audience and I see young doctors and I’ve got shoes older than them. You can laugh in my jokes, you know. But anyway, so triple arthrodesis is a challenging operation that is artistic as it is surgical.
You want to know why John Ruck is such a great surgeon? He’s an anal artist.
That’s how he handles tissue. And I look at all the surgeons that I’ve trained including him and appreciate the fact that we all have our areas of greatness and ability. But the most important thing is how you handle the tissues. So picking internal combination, adjunctive mechanical bones stim, orthobiologic.
Here’s a classical orthopedic triple arthrodesis with staples. Good job, except for the non-union. She came in to me just a week ago. This was done almost 35 years ago. A very good guy and she has to pay. What did I do? I injected that joint, let’s see how you do. She does well, I’ll inject it in three months. If not, I’ll fuse it, probably percutaneously.
Here’s a closer staples and 6.5, great fusion three years. Here’s another case. The first AO triple with a large screw in 1980s with bone stim. It’s unique, you should be proud of it. We invented it. That’s in combination with medical fusion by the way. Another case here, nine years post, look, Steinmann pins. If it’s good, acceptable position, you haven’t burned bone, you use bone grafting, you held it in position, it will work.
Some other examples here. Here’s one month post a four-screw triple arthrodesis with small cancellous screws compressing TN and CC joint and 6.5 cannulated screw for the subtalar joint. Here’s a 10-year postop. See the fractured screws? Osteosynthesis is raised between the failure of the fixation and the healing of bone. Who gives a damn about the screws fracture when the bone heals? Doesn’t make a difference.
You’ll see later this afternoon, 12 o’clock, I’ll show you how three-dimensional image helps you in getting pictures of the hardware with everything else taken out, just the hardware in the foot, it’s wonderful. Here is a patient of mine, I know HIPAA doesn’t like me putting names in, but I really don’t give a damn. But here, he had what the infectious disease guy saw as an infection. Now, I don’t know the article but I just read it a couple of years ago, I should have put it in here. In fact, I forgot to. Where they’re now talking about leaving a hardware in, especially after hip surgery in the presence of infection. But every infectious disease doctor I ever ran into tells you to take out all the hardware when he thinks there’s an infection.
No, you wind up with an unstable limb which is chronically swollen, get rid of the infection and you got to do something else. Sometimes, and it’s your call, you can leave the fixation in. We took the fixation out, treat them with IV antibiotics because it was written all over the chart, osteomyelitis post triple, nonsense. It was avascular necrosis.
Sometimes after that, it’s necessary to stay away from another fixation internally, but put a frame on. Okay. So let’s look at some other 10-year post triple arthrodesis with one, two, three, four, five, six screws, okay? Severe Charcot, absolutely we will talk about three-dimensional CT imaging for triple arthrodesis.
And oh, I didn’t know I had this picture. When you do have hardware failure, if you have the three-dimensional image that you can create, you can strip away everything and just look at the hardware itself to see the fixation.
So to me, a real triple, being that I had a son who was NCAA national baseball champion and he was at the Yankee Stadium, and invited, because he’s a famous artist, Michael Kalish, you can Google him. And he got in there and he was NCAA national and Joe Pepitone said, “We don’t want you to hurt your hands because, you know, you’re an artist.” And he threw the first pitch and he hit it into the unopened, never seen real game center field fence.
And Pepitone began a tirade of F words, who the are you? And that was a fun day for me.
I will tell you, as I look at Harold, who I love dearly and has been a friend of mine for many years, that half your life, ladies and gentlemen, is making memories. The other half is remembering them. I will tell you, I am so proud of what this meeting turned into from three guys in an anatomy lab to this marvelous presentation that Present and Allen and Michael have done and me as a scientific chairman turning the reigns over to a very competent and dear friend, Harold Schoenhaus.
To thank you very much. I hope I enlightened you a little bit on triple arthrodesis. And, of course, if you have any questions, I’m here to answer them. Thank you.
TAPE ENDS - [31:07]