Triple Arthrodesis Insights

The triple arthrodesis procedure is a surgery where three joints of the foot are fused together in order to stabilize the foot and to take pain away. The three joints that are fused together in a triple arthrodesis are the talonavicular joint, the subtalar joint, and the calcaneocuboid joint.

Typical conditions for a triple arthrodesis are severe arthritis of the hindfoot and midfoot, e.g. by rheumatoid arthritis, and severe deformities of the foot like severe flatfoot. Often, no sufficient pain relief is achieved by physical therapy or by using orthotics and therefore a surgical treatment is considered. Patients suffering from rheumatoid arthritis often have autoimmune inflammation of their joints. In addition to swelling of the skin and soft tissues around the affected joints the cartilage inside the joints will slowly be destructed. The resulting chronic pain and decreased mobility of the affected joints will often not be relieved sufficiently by physical therapy. Flatfoot can cause severe pain and progressive deformation of the foot due to collapse of the arch of the foot. This can cause misalignment of the heel bones and increased stress on the ankle joint and other joints in the foot. Such problems often cannot be solved sufficiently by using orthotics, and therefore a surgical treatment like a triple arthrodesis is performed (Knupp et al., 2008; Fadle et al., 2021).

The benefits to triple arthrodesis are great and provide significant relief of pain in the foot in patients who are indicated for the surgery. The vast majority of patients who have triple arthrodesis are able to participate in physical activity without significant pain, as the fusion that occurs in triple arthrodesis from the talonavicular joint, through the subtalar joint, and to the calcaneocuboid joint, of the foot provides support to the foot. Thus, these patients have an improved level of function and go through life with improved mobility. In most cases, patient are greatly relieved of their pain, and many of these patients comment on the great feeling of support provided to their foot by the fused joints (Muscarella et al., 2012; Mirmiran et al., 2014).

In summary, triple arthrodesis is a crucial surgery that patients with severe pain in their feet and structural problems in their feet need in order to be able to return to normal activity with the least amount of pain possible and return to normal function of the foot. The method of triple arthrodesis involves the fusion of three joints in the foot: the talonavicular, subtalar and calcaneocuboid joints. Many different techniques of surgery for triple arthrodesis exist. There are many different open methods that allow for exposure to the joint of interest. Many different minimally invasive techniques also exist and these techniques usually involve the use of very small incisions to access the joint of interest. The type of surgical method that a surgeon uses is very often determined by the surgeons own preferences as well as by the type and degree of pathology that exists in the foot of the patient. As was stated previously, the open technique allows for better visualization of the joint than that of the minimally invasive technique. On the other hand, the use of a minimally invasive technique can cause less damage to the soft tissues of the foot and allow for the patient to return to activity more quickly than that of an open technique. Many authors have written about the various different techniques that exist for performing a triple arthrodesis. Phisitkul et al. (2013) wrote about the various different techniques that exist for performing a triple arthrodesis of the subtalar joint and Brilhault (2009) explained the method for performing a triple arthrodesis.

As for any foot and ankle surgery, a number of considerations must be taken into account by the surgeon to achieve the desired end result. First and foremost, the vascular supply to the foot must be maintained. Preoperatively, it is wise to assess the blood vessels in the area where the incision(s) will be made in order to prevent any potential compromise to the blood supply. As Koutsouradis and colleagues (2021) noted, the vascular supply to the foot must be taken into consideration to prevent potential complications such as a nonhealing wound and/or infection. In addition, great attention must be given to the alignment of the involved joints as well as the overall biomechanical function of the foot. This will enable the patient to ambulate without difficulty and to transfer weight onto the foot as intended.

Rehabilitation after a Triple Arthrodesis is an important process. After surgery, patients usually are in the hospital for a short period of time. They are usually administered pain control and monitored closely. Initially, the foot is elevated and placed in a splint or cast to protect the fused joints from excessive stress and motion. Patients are instructed not to place weight on their foot for several weeks postoperatively, depending on their surgeon’s recommendations. As the patient begins their rehabilitation, they are given instructions on how to care for the surgical site and manage any swelling. Postoperatively, patients can begin to strengthen the muscles of the ankle and foot as well as improve mobility. Patients are usually put into physical therapy about 6-8 weeks postoperatively. During therapy, patients are taught exercises to increase flexibility as well as strengthen muscles around the ankle and foot. In the initial stages of exercises, patients are usually started with low intensity exercises and gradually increase in intensity of exercises as the patient becomes stronger and more flexible (Nielsen et al., 2008; Mirmiran et al., 2014).

A critical part of the recovery process is gradually beginning to weight bear through the foot. This is often started in physical therapy and done under the care of the treating physician. As the patient progresses through rehabilitation, the amount of weight that is placed on the affected side of the foot is slowly increased. Ultimately, the goal of rehabilitation after a triple arthrodesis is to return the patient to maximum activity. While some patients may note a slight decrease in mobility, most are able to return to their prior level of function.

Triple arthrodesis is a surgical procedure that has its risks as do all forms of surgery. The major concern in the post-operative period is that of nonunion (i.e., failure of the bones to fuse in place). This can be a very painful condition leading to instability of the foot and potentially the requirement for further surgery. Infection is another risk, though due to current use of powerful antibiotics and stringent sterilization techniques this is a rare occurrence. However, an infection would most likely need to be treated with oral or intravenous antibiotics and possibly require further surgery to clear out any infected tissue. Finally, post-operative chronic pain is a potential complication of this operation and can interfere with a person’s activities greatly and even prevent them from walking.

Despite the risks associated with triple arthrodesis, the procedure is very effective for many patients and significantly improves their quality of life. Most patients are very satisfied with their surgery, reporting that the increased stability of their foot and decreased pain allows them to participate in a wide variety of activities. According to the results of studies that have followed large groups of patients for long periods of time, a large percentage of patients report improvement in their ability to walk and in their overall quality of life following triple arthrodesis. This procedure is often considered to be one of the few options for patients with severe deformity and/or pain of the foot, and it can be very effective for such patients. Although complications and continued pain can occur following triple arthrodesis, they are not typically experienced by the majority of patients. As a result, the benefits of this procedure far outweigh the risks for most individuals with conditions of the foot that require this type of surgery.

Citations:

Knupp, M., Stufkens, S.A. and Hintermann, B., 2011. Triple arthrodesis. Foot and ankle clinics, 16(1), pp.61-67. https://www.foot.theclinics.com/article/S1083-7515(10)00092-6/abstract

Knupp, M., Skoog, A., Törnkvist, H. and Ponzer, S., 2008. Triple arthrodesis in rheumatoid arthritis. Foot & ankle international, 29(3), pp.293-297. https://journals.sagepub.com/doi/abs/10.3113/FAI.2008.0293

Phisitkul, P., Haugsdal, J., Vaseenon, T. and Pizzimenti, M.A., 2013. Vascular disruption of the talus: comparison of two approaches for triple arthrodesis. Foot & ankle international, 34(4), pp.568-574. https://journals.sagepub.com/doi/abs/10.1177/1071100713479318

Mirmiran, R., Wilde, B. and Nielsen, M., 2014. Retrospective analysis of the rate and interval to union for joint arthrodesis of the foot and ankle. The Journal of Foot and Ankle Surgery, 53(4), pp.420-425. https://www.sciencedirect.com/science/article/pii/S1067251613005759

Muscarella, V., Sadri, S. and Pusateri, J., 2012. Indications and considerations of foot and ankle arthrodesis. Clinics in Podiatric Medicine and Surgery, 29(1), pp.1-9. https://www.podiatric.theclinics.com/article/S0891-8422(11)00103-0/abstract

Brilhault, J., 2009. Single medial approach to modified double arthrodesis in rigid flatfoot with lateral deficient skin. Foot & Ankle International, 30(1), pp.21-26. https://journals.sagepub.com/doi/abs/10.3113/FAI.2009.0021

Marx, R.C. and Mizel, M.S., 2010. What’s new in foot and ankle surgery. JBJS, 92(2), pp.512-523. https://journals.lww.com/jbjsjournal/fulltext/2010/02000/what_s_new_in_foot_and_ankle_surgery.37.aspx

Koutsouradis, P., Savvidou, O.D. and Stamatis, E.D., 2021. Arthrodesis of the first metatarsophalangeal joint: The “when and how”. World Journal of Orthopedics, 12(7), p.485. https://pmc.ncbi.nlm.nih.gov/articles/PMC8316842/

Fadle, A.A., El-Adly, W., Attia, A.K., Mohamed, M.M.M., Mohamadean, A. and Osman, A.E., 2021. Double versus triple arthrodesis for adult-acquired flatfoot deformity due to stage III posterior tibial tendon insufficiency: a prospective comparative study of two cohorts. International Orthopaedics, 45(9), pp.2219-2229. https://link.springer.com/article/10.1007/s00264-021-05041-1

Nielsen, K.K., Linde, F. and Jensen, N.C., 2008. The outcome of arthroscopic and open surgery ankle arthrodesis: a comparative retrospective study on 107 patients. Foot and ankle surgery, 14(3), pp.153-157. https://www.sciencedirect.com/science/article/pii/S1268773108000040