Primary Triple Arthrodesis for Management of Rigid Flatfoot Deformity.

INTRODUCTION

Primary triple arthrodesis is a powerful and reliable procedure for stabilizing and correcting painful rigid flatfoot deformities with a low rate of complications.

STEP 1 PREOPERATIVE PLANNING: Pay careful attention to the history, physical examination, and weight-bearing radiographic studies as they are critical for selecting patients who will benefit from a triple arthrodesis.

STEP 2 ROOM SETUP AND PATIENT POSITIONING: Position the patient supine on the operating table with the toes pointing straight up to the ceiling.

STEP 3 INCISIONS AND EXPOSURE: For a standard triple arthrodesis, use 2 incisions: a lateral sinus tarsi incision, which allows exposure of the subtalar joint, CC joint, and lateral aspect of the TN joint, and a medial incision, which provides exposure of the TN joint.

STEP 4 JOINT PREPARATION: Ensure that joint preparation is thorough as this is critical for the success of any hindfoot arthrodesis.

STEP 5 REDUCTION OF DEFORMITY: Reduce the TN joint first, followed by the subtalar joint, restoring a plantigrade foot and approximately 5° of hindfoot valgus alignment.

STEP 6 JOINT FIXATION: Perform rigid fixation of the subtalar joint first, followed by fixation of the TN and CC joints.

STEP 7 ACCESSORY PROCEDURES: Accessory procedures are often required in addition to the triple arthrodesis to ensure that appropriate hindfoot alignment and a plantigrade foot are achieved.

STEP 8 WOUND CLOSURE: Perform a staged wound closure, taking care to maximize soft-tissue coverage over the involved hindfoot joints.

STEP 9 POSTOPERATIVE CARE: Ensure that the patient follows strict non-weight-bearing precautions in the immediate postoperative period to limit micromotion at the arthrodesis sites and allow for timely fusion.

RESULTS

In one of the largest published series of patients managed with triple arthrodesis (111 patients), Pell et al. reported a union rate of 98% at a minimum follow-up of 2 years, with 91% of patients indicating that they would be willing to repeat the procedure under similar circumstances4.