Triple Arthrodesis Workup

  • Author: Stephen M Schroeder, DPM; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Aug 16, 2011
 

Laboratory Studies

  • If the underlying pathology is obvious and the pain is generated from DJD, no specific laboratory tests are warranted except for standard preoperative studies.
  • When the underlying diagnosis is not as clear, however, arthritis panels may be ordered to rule out inflammatory arthropathies or gout.
  • If Charcot arthropathy is suspected, imaging studies or bone biopsy are the studies of choice.
  • Joint-fluid analysis can also be performed if gout or an infectious process is suspected.
Next

Imaging Studies

  • Radiographic studies
    • Standard anteroposterior (AP), lateral, and oblique weight-bearing radiographs are obtained as part of the initial workup.
    • In severe cases, ankle, weight-bearing AP, and mortise views should be included.
    • The 3 joints in question are examined for degenerative changes manifested by joint-space narrowing, subchondral sclerosis, cyst formation, and osteophytic projection.
      • Osteophytes are easily identified at the TN and CC joints on the lateral and oblique views (see image below).Osteophytes and degenerative joint disease easily Osteophytes and degenerative joint disease easily seen at the talonavicular, calcaneocuboid, and subtalar joints.
      • The AP view reveals joint-space narrowing and abduction (common in valgus deformity) or adduction (common in varus deformity) of the forefoot (see first image below). One can also appreciate the amount of uncovering of the articular surface on the talar head that is rotated medially from the concave articular surface of the navicular. More than 7° displacement is considered abnormal and is commonly found in a valgus deformity with abduction of the forefoot (see second image below). Anteroposterior view depicting talonavicular and cAnteroposterior view depicting talonavicular and calcaneocuboid joints. Articular surface on the talar head rotated medialArticular 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.
      • The lateral view shows arch height. A low or collapsed arch indicates a valgus deformity, and a high arch indicates a varus or cavovarus deformity.
    • A useful adjunctive radiographic view is the Harris-Beath projection, which is taken with weight bearing, with the beam directed toward the posterior heel. Three views are shot with the first angled 10° above the level of the declination angle of the posterior facet, the second angled at the same level, and the third angled 10° below. This allows the examiner to see the posterior facet joint space for pathology as well as the amount of varus or valgus deformity in the rearfoot relative to the tibia (see image below). Harris-Beath projection allowing visualization of Harris-Beath projection allowing visualization of the posterior facet of the subtalar joint and varus/valgus rotation.
    • Another adjunctive radiographic study is a standing full-length view of the legs. This is done to evaluate the mechanical axis of the tibia to the ground in patients with excessive genu varum. It becomes important because the foot must be fused in a position to accommodate these angles.[3] An example of this is a patient with 10° of tibia vara. The STJ must be fused in at least 10° of valgus (rearfoot relative to tibia) in order to position the foot perpendicular to the ground. Fusing the foot in a varus position often leads to complications and should be avoided.
  • MRIs and CT scans: These are rarely obtained as part of a workup for triple arthrodesis. MRI can be useful, however, if avascular necrosis of the talus or navicular is suspected. It can also be helpful in identifying the extent of an infectious process or Charcot arthropathy.
  • Important normal joint angles to keep in mind when examining imaging study findings are as follows (see images below):Lateral view demonstrating talocalcaneal angle (yeLateral 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 talocalcaneAnteroposterior 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).
    • Lateral view
      • TC angle of 25-50°
      • Talus, first metatarsal angle of 0°
      • Calcaneal inclination angle of 20-25°
    • AP view
      • TC angle of 15-50°
      • Talus, first metatarsal angle of 0°
      • Degree of talar head rotation less than 7° from the navicular
Previous
Next

Other Tests

  • Coleman block test
    • Cavovarus deformities in the rear foot can result from a forefoot cavus deformity or an isolated plantarflexed first metatarsal. In these situations, the rearfoot compensates by rotating into varus.
    • The Coleman block test is used to determine if the deformity is in the forefoot or hindfoot and to see if the deformity is reducible.
    • The forefoot is "off-weighted" by placing a block under the heel so that the rearfoot no longer has to compensate for a forefoot cavus.
    • If the rearfoot normalizes and becomes perpendicular to the ground, the deformity lies in the forefoot and should be addressed as part of the procedure.
    • In rigid cavovarus foot, the deformity does not reduce.
Previous
Next

Diagnostic Procedures

  • Bone biopsy: As mentioned above, if Charcot arthropathy is suspected, imaging modalities or bone biopsy are the studies of choice.
  • Diagnostic local anesthesia blocks: One of the most reliable office procedures for isolating joint pain from other pain generators is local intra-articular anesthetic blocks.
    • Relief of pain after injection confirms the location of the pain generator.
    • Care must be taken to inject only into the joint, so surrounding structures do not become anesthetized. STJ injections are performed through the sinus tarsi.
    • The sinus tarsi is palpated on the lateral aspect of the foot and a 1.5-inch needle is directed toward a point just inferior to the sustentaculum tali on the medial side of the foot (see images below). 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.
    • The TN and CC joints may be more difficult to inject, especially when osteophytes are present, and may require fluoroscopic or ultrasound guidance.
Previous
Proceed to Treatment & Management
 
 
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 A Blume, DPM, FACFAS  Assistant Clinical Professor of Surgery, Department of Surgery, Yale University School of Medicine; Assistant Clinical Professor of Orthopedics and Rehabilitation, Department of Orthopedics and Rehabilitation, Section of Podiatric Surgery, Yale University School of Medicine

Peter A Blume, DPM, FACFAS is a member of the following medical societies: American Association of Hospital and Healthcare Podiatrists, 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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

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.

References

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

  2. Knupp M, Stufkens SA, Hintermann B. Triple arthrodesis. Foot Ankle Clin. Mar 2011;16(1):61-7. [Medline].

  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. 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].

  10. 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].

  11. Coughlin MJ, Smith BW, Traughber P. The evaluation of the healing rate of subtalar arthrodeses, part 2: the effect of low-intensity ultrasound stimulation. Foot Ankle Int. Oct 2008;29(10):970-7. [Medline].

 
Previous
Next
 
CT scan of a calcaneal fracture shows a prominent lateral wall with the heel rotated into varus.
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. 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 exhibiting shortening and widening.
Medial arch collapse associated with valgus deformity.
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 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 abducted forefoot and collapsed medial arch.
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-Marie-Tooth disease.
Cavovarus deformity with high-arched foot. Note the hammertoe deformity to all 5 digits common to this condition.
Triple arthrodesis. Cavovarus with high-arched foot, hammertoe deformity, adducted forefoot, and severely plantarflexed first metatarsal.
Cavovarus with high-arched foot, hammertoe deformity, adducted forefoot, and severely plantarflexed first metatarsal.
After calcaneal osteotomy and metatarsal osteotomy.
Osteophytes and degenerative joint disease easily seen at the talonavicular, calcaneocuboid, and subtalar joints.
Anteroposterior view depicting talonavicular and calcaneocuboid joints.
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 the posterior facet of the subtalar joint and varus/valgus rotation.
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 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.
Subtalar joint injection via the sinus tarsi.
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 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 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.
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 incision, (B) medial malleolus, (C) posterior tibial tendon, (D) tibialis anterior tendon, (E) saphenous vein.
Lateral view showing subtalar joint arthrodesis with 7.3 cannulated screw going from talus to calcaneus.
Lateral view showing a subtalar joint arthrodesis using a 7.0 cannulated screw from the calcaneus into the talus.
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.