eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Triple Arthrodesis: Multimedia

Author: Stephen M Schroeder, DPM, Chief of Podiatric Foot and Ankle Surgery, Southwest Washington Medical Center
Coauthor(s): Enzo Sella, MD, Chief, Orthopedic Foot and Ankle Surgery, Yale-New Haven Hospital; Associate Clinical Professor, Department of Orthopedics and Rehabilitation, Yale University School of Medicine; Peter Blume, DPM, FACFAS, Assistant Clinical Professor of Surgery, Orthopaedics and Rehabilitation and Anesthesia, Yale School of Medicine, Yale New Haven Hospital; Director of North American Center for Limb Preservation; Raymond O'Hara, DPM, Chief Resident, Department of Orthopedic Surgery, Yale-New Haven Hospital
Contributor Information and Disclosures

Updated: Feb 28, 2008

Multimedia

CT scan of a calcaneal fracture shows a prominent...Media file 1: CT scan of a calcaneal fracture shows a prominent lateral wall with the heel rotated into varus.
CT scan of a calcaneal fracture shows a prominent...

CT scan of a calcaneal fracture shows a prominent lateral wall with the heel rotated into varus.

Lateral wall blowout fracture with comminution. N...Media file 2: Lateral wall blowout fracture with comminution. Note the shortening and widening of the heel. If left untreated, the heel would remain in varus with an uneven lateral wall and bony prominence that could become irritated.
Lateral wall blowout fracture with comminution. N...

Lateral wall blowout fracture with comminution. Note the shortening and widening of the heel. If left untreated, the heel would remain in varus with an uneven lateral wall and bony prominence that could become irritated.

Lateral wall blowout fracture with comminution. N...Media file 3: Lateral wall blowout fracture with comminution. Note the shortening and widening of the heel. If left untreated, the heel would remain in varus with an uneven lateral wall and bony prominence that could become irritated.
Lateral wall blowout fracture with comminution. N...

Lateral wall blowout fracture with comminution. Note the shortening and widening of the heel. If left untreated, the heel would remain in varus with an uneven lateral wall and bony prominence that could become irritated.

Relatively mild calcaneal fracture still exhibiti...Media file 4: Relatively mild calcaneal fracture still exhibiting shortening and widening.
Relatively mild calcaneal fracture still exhibiti...

Relatively mild calcaneal fracture still exhibiting shortening and widening.

Medial arch collapse associated with valgus defor...Media file 5: Medial arch collapse associated with valgus deformity.
Medial arch collapse associated with valgus defor...

Medial arch collapse associated with valgus deformity.

Valgus foot deformity with medial dislocation of ...Media file 6: Valgus foot deformity with medial dislocation of the talar head. Notice the abducted forefoot and the head of the talus rotated medially on the navicular.
Valgus foot deformity with medial dislocation of ...

Valgus foot deformity with medial dislocation of the talar head. Notice the abducted forefoot and the head of the talus rotated medially on the navicular.

Valgus foot deformity with medial dislocation of ...Media file 7: Valgus foot deformity with medial dislocation of the talar head. Notice the abducted forefoot and the head of the talus rotated medially on the navicular.
Valgus foot deformity with medial dislocation of ...

Valgus foot deformity with medial dislocation of the talar head. Notice the abducted forefoot and the head of the talus rotated medially on the navicular.

Clinical view of a valgus foot deformity with abd...Media file 8: Clinical view of a valgus foot deformity with abducted forefoot and collapsed medial arch.
Clinical view of a valgus foot deformity with abd...

Clinical view of a valgus foot deformity with abducted forefoot and collapsed medial arch.

Valgus deformity with medial talar rotation that ...Media file 9: Valgus deformity with medial talar rotation that is so severe that the patient bears weight on the head of the talus.
Valgus deformity with medial talar rotation that ...

Valgus deformity with medial talar rotation that is so severe that the patient bears weight on the head of the talus.

Varus foot deformity in a patient with Charcot-Ma...Media file 10: Varus foot deformity in a patient with Charcot-Marie-Tooth disease.
Varus foot deformity in a patient with Charcot-Ma...

Varus foot deformity in a patient with Charcot-Marie-Tooth disease.

Cavovarus deformity with high-arched foot. Note t...Media file 11: Cavovarus deformity with high-arched foot. Note the hammertoe deformity to all 5 digits common to this condition.
Cavovarus deformity with high-arched foot. Note t...

Cavovarus deformity with high-arched foot. Note the hammertoe deformity to all 5 digits common to this condition.

Triple arthrodesis. Cavovarus with high-arched fo...Media file 12: Triple arthrodesis. Cavovarus with high-arched foot, hammertoe deformity, adducted forefoot, and severely plantarflexed first metatarsal.
Triple arthrodesis. Cavovarus with high-arched fo...

Triple arthrodesis. Cavovarus with high-arched foot, hammertoe deformity, adducted forefoot, and severely plantarflexed first metatarsal.

Cavovarus with high-arched foot, hammertoe deform...Media file 13: Cavovarus with high-arched foot, hammertoe deformity, adducted forefoot, and severely plantarflexed first metatarsal.
Cavovarus with high-arched foot, hammertoe deform...

Cavovarus with high-arched foot, hammertoe deformity, adducted forefoot, and severely plantarflexed first metatarsal.

Same foot as in Images 12-13 after calcaneal oste...Media file 14: Same foot as in Images 12-13 after calcaneal osteotomy and metatarsal osteotomy.
Same foot as in Images 12-13 after calcaneal oste...

Same foot as in Images 12-13 after calcaneal osteotomy and metatarsal osteotomy.

Osteophytes and degenerative joint disease easily...Media file 15: Osteophytes and degenerative joint disease easily seen at the talonavicular, calcaneocuboid, and subtalar joints.
Osteophytes and degenerative joint disease easily...

Osteophytes and degenerative joint disease easily seen at the talonavicular, calcaneocuboid, and subtalar joints.

Anteroposterior view depicting talonavicular and ...Media file 16: Anteroposterior view depicting talonavicular and calcaneocuboid joints.
Anteroposterior view depicting talonavicular and ...

Anteroposterior view depicting talonavicular and calcaneocuboid joints.

Articular surface on the talar head rotated media...Media file 17: Articular surface on the talar head rotated medially from the concave articular surface of the navicular. More than 7° of displacement is considered abnormal and is commonly found in a valgus deformity with abduction of the forefoot.
Articular surface on the talar head rotated media...

Articular surface on the talar head rotated medially from the concave articular surface of the navicular. More than 7° of displacement is considered abnormal and is commonly found in a valgus deformity with abduction of the forefoot.

Harris-Beath projection allowing visualization of...Media file 18: Harris-Beath projection allowing visualization of the posterior facet of the subtalar joint and varus/valgus rotation.
Harris-Beath projection allowing visualization of...

Harris-Beath projection allowing visualization of the posterior facet of the subtalar joint and varus/valgus rotation.

Lateral view demonstrating talocalcaneal angle (y...Media file 19: Lateral view demonstrating talocalcaneal angle (yellow angle marker), talus first metatarsal angle (black angle marker), and calcaneal inclination angle (red angle marker).
Lateral view demonstrating talocalcaneal angle (y...

Lateral view demonstrating talocalcaneal angle (yellow angle marker), talus first metatarsal angle (black angle marker), and calcaneal inclination angle (red angle marker).

Anteroposterior view demonstrating the talocalcan...Media file 20: Anteroposterior view demonstrating the talocalcaneal angle (black angle marker), talus first metatarsal angle (red angle marker), and degree of talar head rotation from the navicular (yellow marker).
Anteroposterior view demonstrating the talocalcan...

Anteroposterior view demonstrating the talocalcaneal angle (black angle marker), talus first metatarsal angle (red angle marker), and degree of talar head rotation from the navicular (yellow marker).

Subtalar joint injection via the sinus tarsi.Media file 21: Subtalar joint injection via the sinus tarsi.
Subtalar joint injection via the sinus tarsi.

Subtalar joint injection via the sinus tarsi.

Subtalar joint injection via the sinus tarsi.Media file 22: Subtalar joint injection via the sinus tarsi.
Subtalar joint injection via the sinus tarsi.

Subtalar joint injection via the sinus tarsi.

A lateral incision is made from just inferior to ...Media file 23: A lateral incision is made from just inferior to the distal tip of the lateral malleolus to the base of the fourth metatarsal. This allows exposure to the subtalar joint, calcaneocuboid joint, and the lateral portion of the talonavicular joint. Care is taken to avoid branches of the sural and superficial peroneal nerves running just inferior and superior to the incision. This approach follows a plane between both nerves, but small branches may enter the area and should be avoided if possible.
A lateral incision is made from just inferior to ...

A lateral incision is made from just inferior to the distal tip of the lateral malleolus to the base of the fourth metatarsal. This allows exposure to the subtalar joint, calcaneocuboid joint, and the lateral portion of the talonavicular joint. Care is taken to avoid branches of the sural and superficial peroneal nerves running just inferior and superior to the incision. This approach follows a plane between both nerves, but small branches may enter the area and should be avoided if possible.

Anatomy of the lateral incision: (A) lateral inci...Media file 24: Anatomy of the lateral incision: (A) lateral incision, (B) lateral malleolus, (C) base of fourth metatarsal, (D) base of fifth metatarsal, (E) peroneal tendons, (F) sural nerve, (G) intermediate dorsal cutaneous nerve.
Anatomy of the lateral incision: (A) lateral inci...

Anatomy of the lateral incision: (A) lateral incision, (B) lateral malleolus, (C) base of fourth metatarsal, (D) base of fifth metatarsal, (E) peroneal tendons, (F) sural nerve, (G) intermediate dorsal cutaneous nerve.

Deep structures encountered through the lateral i...Media file 25: Deep structures encountered through the lateral incision: (A) Hoke tonsil before removal, (B) L-incision along insertion of EDB and across the calcaneocuboid joint, (C) deep fascia over the extensor digitorum brevis.
Deep structures encountered through the lateral i...

Deep structures encountered through the lateral incision: (A) Hoke tonsil before removal, (B) L-incision along insertion of EDB and across the calcaneocuboid joint, (C) deep fascia over the extensor digitorum brevis.

Hoke tonsil being evacuated.Media file 26: Hoke tonsil being evacuated.
Hoke tonsil being evacuated.

Hoke tonsil being evacuated.

A medial incision is made beginning just anterior...Media file 27: A medial incision is made beginning just anterior to the distal tip of the medial malleolus extending dorsal medially to the naviculocuneiform joint. It lies between the anterior and posterior tibial tendons. The saphenous vein and nerve are typically located slightly dorsal to the incision and should be carefully retracted away during the dissection.
A medial incision is made beginning just anterior...

A medial incision is made beginning just anterior to the distal tip of the medial malleolus extending dorsal medially to the naviculocuneiform joint. It lies between the anterior and posterior tibial tendons. The saphenous vein and nerve are typically located slightly dorsal to the incision and should be carefully retracted away during the dissection.

Anatomy of the medial incision: (A) medial incisi...Media file 28: Anatomy of the medial incision: (A) medial incision, (B) medial malleolus, (C) posterior tibial tendon, (D) tibialis anterior tendon, (E) saphenous vein.
Anatomy of the medial incision: (A) medial incisi...

Anatomy of the medial incision: (A) medial incision, (B) medial malleolus, (C) posterior tibial tendon, (D) tibialis anterior tendon, (E) saphenous vein.

Lateral view showing subtalar joint arthrodesis w...Media file 29: Lateral view showing subtalar joint arthrodesis with 7.3 cannulated screw going from talus to calcaneus.
Lateral view showing subtalar joint arthrodesis w...

Lateral view showing subtalar joint arthrodesis with 7.3 cannulated screw going from talus to calcaneus.

Lateral view showing a subtalar joint arthrodesis...Media file 30: Lateral view showing a subtalar joint arthrodesis using a 7.0 cannulated screw from the calcaneus into the talus.
Lateral view showing a subtalar joint arthrodesis...

Lateral view showing a subtalar joint arthrodesis using a 7.0 cannulated screw from the calcaneus into the talus.

Can you identify the type of special hardware use...Media file 31: Can you identify the type of special hardware used for this talonavicular arthrodesis? Subchondral bone in a joint with degenerative joint disease can be very sclerotic and hard. It may be wise to extend the guide hole from the near cortex in the navicular all the way through the talonavicular joint and into the talus, even when using cannulated screws that are self-drilling and self-tapping. The corkscrew-appearing hardware is the threads from a cannulated screw that delaminated off the implant while trying to cut through the subchondral bone in the talar head.
Can you identify the type of special hardware use...

Can you identify the type of special hardware used for this talonavicular arthrodesis? Subchondral bone in a joint with degenerative joint disease can be very sclerotic and hard. It may be wise to extend the guide hole from the near cortex in the navicular all the way through the talonavicular joint and into the talus, even when using cannulated screws that are self-drilling and self-tapping. The corkscrew-appearing hardware is the threads from a cannulated screw that delaminated off the implant while trying to cut through the subchondral bone in the talar head.

More on Triple Arthrodesis

Overview: Triple Arthrodesis
Workup: Triple Arthrodesis
Treatment: Triple Arthrodesis
Follow-up: Triple Arthrodesis
Multimedia: Triple Arthrodesis
References

References

  1. Ryerson EW. Arthrodesing operations on the feet. J Bone Joint Surg. 1923;5:453-71.

  2. Goecker RM, Ruch JA. Rearfoot arthrodesis. In: Banks AS, Downey MS, Martin DE, Miller SJ, eds. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. Vol 2. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins; 2001: 1167-92.

  3. Amis JA. Talus-Calcaneus-Cuboid (Triple) Arthrodesis. In: Johnson KA, ed. The Foot and Ankle. New York: Raven;. 1994: 369-400.

  4. Suckel A, Muller O, Herberts T, Langenstein P, Reize P, Wulker N. Talonavicular arthrodesis or triple arthrodesis: peak pressure in the adjacent joints measured in 8 cadaver specimens. Acta Orthop. Oct 2007;78(5):592-7. [Medline].

  5. Jackson WF, Tryfonidis M, Cooke PH, Sharp RJ. Arthrodesis of the hindfoot for valgus deformity. An entirely medial approach. J Bone Joint Surg Br. Jul 2007;89(7):925-7. [Medline].

  6. Maskill MP, Loveland JD, Mendicino RW, Saltrick K, Catanzariti AR. Triple arthrodesis for the adult-acquired flatfoot deformity. Clin Podiatr Med Surg. Oct 2007;24(4):765-78, x. [Medline].

  7. Bono JV, Jacobs RL. Triple arthrodesis through a single lateral approach: a cadaveric experiment. Foot Ankle. Sep 1992;13(7):408-12. [Medline].

  8. Duncan JW, Lovell WW. Hoke triple arthrodesis. J Bone Joint Surg Am. Sep 1978;60(6):795-8. [Medline].

  9. Fisher J. New ways to heal fractures enter market in the works. Orthop Today. 1996;16(1):24-6.

  10. Gellman H, Lenihan M, Halikis N, et al. Selective tarsal arthrodesis: an in vitro analysis of the effect on foot motion. Foot Ankle. Dec 1987;8(3):127-33. [Medline].

  11. Talarico LM, Vito GR. Triple arthrodesis using external ring fixation and arched-wire compression: an evaluation of 87 patients. J Am Podiatr Med Assoc. Jan-Feb 2004;94(1):12-21. [Medline].

Further Reading

Keywords

joint fusion, talocalcaneal joint, talonavicular joint, calcaneocuboid joint, TC joint, TN joint, CC joint, foot arthrodesis, foot joints, degenerative joint disease, DJD, degenerative arthritis, arthritis, foot arthritis, varus deformity of the foot, valgus deformity of the foot

Contributor Information and Disclosures

Author

Stephen M Schroeder, DPM, Chief of Podiatric Foot and Ankle Surgery, Southwest Washington Medical Center
Stephen M Schroeder, DPM is a member of the following medical societies: American College of Foot and Ankle Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Enzo Sella, MD, Chief, Orthopedic Foot and Ankle Surgery, Yale-New Haven Hospital; Associate Clinical Professor, Department of Orthopedics and Rehabilitation, Yale University School of Medicine
Enzo Sella, MD is a member of the following medical societies: Academy of Medical Royal Colleges, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, and North American Spine Society
Disclosure: Nothing to disclose.

Peter Blume, DPM, FACFAS, Assistant Clinical Professor of Surgery, Orthopaedics and Rehabilitation and Anesthesia, Yale School of Medicine, Yale New Haven Hospital; Director of North American Center for Limb Preservation
Peter Blume, DPM, FACFAS is a member of the following medical societies: American College of Foot and Ankle Surgeons, American Diabetes Association, American Podiatric Medical Association, and International College of Angiology
Disclosure: Nothing to disclose.

Raymond O'Hara, DPM, Chief Resident, Department of Orthopedic Surgery, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

Medical Editor

Heidi M Stephens, MD, MBA, Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health
Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Florida Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS, Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center
Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

 
 
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