Triple Arthrodesis

 

 

 

DEFINITION

Triple arthrodesis involves fusion of the talocalcaneal, calcaneocuboid, and talonavicular joints. The procedure is most commonly indicated for salvage in severe, rigid deformities of the hindfoot which are unresponsive to less invasive methods of treatment.

This procedure is typically considered in adolescents but has been reported in children as young as 8 years of age.

 

 

ANATOMY

 

Joints of the hindfoot: the ankle, subtalar, talonavicular, and the calcaneocuboid joints

 

Ankle joint motion: plantarflexion and dorsiflexion. Dorsiflexion is associated with outward deviation of the foot, whereas plantarflexion is associated with inward deviation.

 

Subtalar (talocalcaneal) joint components: anterior, middle, and a posterior facet. The anterior and middle facets are confluent in a subset of patients. Although there is considerable variation, this joint is usually oriented 23 degrees medially in the transverse plane and 42 degrees dorsally in the sagittal plane. The subtalar joint thus functions as a hinge along an inclined axis and serves as the linkage between the ankle and the distal articulations of the foot. During the gait cycle, the subtalar joint is everted at heel strike and then inverts progressively until push off.

 

The transverse tarsal joints: These include the talonavicular and calcaneocuboid joints. When the calcaneus is everted, these joints become parallel, and there is greater flexibility at the articulation. This aids in shock absorption during initial contact and early stance phase. In contrast, the transverse tarsal joints become nonparallel and more rigid when the calcaneus is inverted. Functionally, the calcaneus becomes inverted during late stance phase, which locks the transverse tarsal joints and provides a rigid lever for push off.

 

Muscles crossing the ankle and subtalar joints:

 

 

Ankle plantarflexors: gastrocnemius and soleus, tibialis posterior, flexor digitorum longus, flexor hallucis longus

 

 

Ankle dorsiflexors: tibialis anterior, extensor digitorum longus, extensor hallucis longus Subtalar inverters: tibialis anterior and posterior, flexor digitorum longus, flexor hallucis longus

 

Subtalar everters: peroneus longus, brevis, tertius, extensor digitorum longus, extensor hallucis longus

 

PATHOGENESIS

 

Congenital conditions causing foot deformities: clubfoot, vertical talus, tarsal coalition

 

Neuromuscular diseases causing foot deformities: cerebral palsy, polio, myelomeningocele, hereditary motor

and sensory neuropathies. The etiology involves muscle weakness and/or imbalance.

 

The most common deformities are equinovarus, equinovalgus, and cavovarus. Calcaneovalgus, calcaneovarus, calcaneocavus, and equinocavus may also be seen. This spectrum of deformities may result from soft tissue contractures, from bony malalignment, or from both.

 

Although some deformities have a structural component at birth, the majority develop gradually, are initially flexible, and only become fixed or rigid over time. Although a loss of passive motion may result from contracture of the soft tissue elements, progressive adaptive changes in the osteocartilaginous structures subsequently result in fixed bony malalignment.

 

Causes of equinovarus deformity: This deformity is present at birth in a congenital clubfoot. Although the etiology/pathogenesis of congenital clubfoot remains debated, it is most likely multifactorial. Equinovarus deformity may result from spastic muscle imbalance in patients with cerebral palsy (most often spastic hemiplegia) or flaccid muscle imbalance in poliomyelitis. The pathogenesis in neuromuscular diseases involves muscle imbalance (strong inversion/plantarflexion and weak eversion/dorsiflexion).

 

Causes of equinovalgus deformity: This deformity is most common in patients with a congenital vertical talus or cerebral palsy (most commonly spastic diplegia).

 

A valgus deformity of the hindfoot is common in patients with a tarsal coalition.

 

Pathogenesis of the cavovarus foot: This deformity is most commonly associated with hereditary motor and sensory neuropathies (Charcot-Marie-Tooth) and results from muscle imbalance. Weakness of the tibialis anterior relative to the peroneus longus is associated with plantarflexion of the first ray. This results in forefoot valgus, a deformity which is initially flexible. Over time, a contracture of the plantar fascia and neighboring intrinsic muscle groups develops. To compensate for forefoot valgus, the hindfoot aligns in varus during stance phase. Over time, both the forefoot valgus and the hindfoot varus become rigid. The hindfoot also appears to be in equinus due to plantarflexion of the midfoot on the hindfoot. A common mistake is to assume that the equinus occurs at the ankle and to perform a tendo Achilles lengthening.

 

NATURAL HISTORY

 

The natural history depends on the underlying disease process. Deformities associated with the neuromuscular diseases will usually progress (and become rigid) over time and will often recur despite treatment due to the underlying disease process.

 

 

 

PATIENT HISTORY AND PHYSICAL FINDINGS

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Patients present with an abnormality or change in appearance of the foot, gait disturbance, pain in the region of the hindfoot, difficulties with shoe wear, or more than one of these. Although the deformities treated by triple arthrodesis may be diagnosed from birth to adolescence, and have often been treated previously, we focus on the older child or adolescent.

 

The history focuses on the presence of symptoms including functional limitations, cosmetic concerns, shoe wear, and on the family history (similar deformities, neuromuscular diseases) and previous treatment.

 

A detailed history is especially important in children of walking age, as a foot deformity may be the first clue to the presence of an underlying neuromuscular problem. Although unilateral foot deformities may be seen with tethering of the spinal cord (or other problems such as a spinal cord tumor), bilateral deformities may be the initial finding in patients with a hereditary motor and sensory neuropathy.

 

The location and character of pain should be determined, in addition to the activities which produce

discomfort.

 

A comprehensive physical examination is required. The spine should be examined to rule out any deformity or evidence of an underlying dysraphic condition, and a careful neurologic examination should be performed.

The extremities are evaluated for alignment, limb lengths, and range of motion. Observational gait analysis should be performed. The shoes should be inspected for patterns of wear, which indicate weight distribution during stance phase.

 

The physical examination of the foot and ankle: Focus on the skin, identifying the presence and location of callosities and points of tenderness. Examine the overall appearance in both the weight bearing and non-weight bearing positions, visualizing the relationship between the forefoot and hindfoot. Check the range of motion of the hindfoot joints. Perform a complete neuromuscular assessment.

 

Tests to perform during the physical examination include the following:

 

 

Range of motion at the ankle joint (plantarflexion and dorsiflexion) to diagnose and determine the magnitude of equinus contracture

 

Range of motion at the subtalar joint (inversion and eversion), which quantifies motion at the subtalar joint. Generally, the amount of inversion is twice the amount of eversion. The total range is 20 to 60 degrees.

 

Range of motion at the transverse tarsal joints

 

Relationship between forefoot and hindfoot alignment, which identifies any coexisting deformity of the forefoot, either varus (dorsiflexion of the medial column relative to the lateral column) or valgus (plantarflexion of the medial column relative to the lateral column)

 

Coleman block test, which determines if hindfoot varus is flexible or rigid

 

Manual muscle testing, which assesses relative strengths of motor units across the ankle and subtalar joints. This helps to diagnose muscle imbalance and to plan tendon transfers if appropriate.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Imaging studies complement the history and physical examination, and plain radiographs, specifically in a weight-bearing position are required in all cases. In addition to a standing anteroposterior (AP) and lateral radiograph of the foot, a standing AP of the ankle should be obtained to determine whether the deformity affects the ankle joint, the subtalar joint, or both locations. Other imaging modalities such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) may be required in selected cases.

 

Plain radiographs are used to evaluate bone and joint morphology, and measuring the angular relationships between the tarsal bones (or segments of the foot) help to further define both the location and the magnitude of deformities.

 

On the standing AP radiograph, measurements include the talocalcaneal (Kite) angle (10 to 56 degrees) and the talo-first metatarsal angle (range −10 to +30 degrees). For the AP talocalcaneal angle, values less than 20 degrees suggest hindfoot varus, whereas an angle greater than 40 to 50 degrees suggests hindfoot valgus.

For the talo-first metatarsal angle, values less than −10 degrees indicate forefoot varus and values greater than +30 degrees indicate forefoot valgus.

 

On the standing lateral radiograph of the foot, measurements include the lateral talocalcaneal angle, the tibiocalcaneal angle, and the talo-first metatarsal angle. For the lateral talocalcaneal angle (range 25 to 55 degrees), values greater than 55 degrees indicate hindfoot valgus or calcaneus, whereas values less than 25 to 30 degrees indicate hindfoot varus or equinus deformities. For the tibiocalcaneal angle (55 to 95 degrees), values greater than 95 degrees suggest equinus, whereas those below 55 degrees are suggestive of

calcaneus. For the talo-first metatarsal, or Meary angle (0 to 20 degrees), values greater than 20 degrees indicate midfoot equinus (cavus), whereas values less than 0 degree indicate midfoot dorsiflexion (midfoot break). The angle of the calcaneus relative to the horizontal axis (calcaneal pitch) is increased with calcaneus or calcaneocavus or with cavovarus deformities.

 

DIFFERENTIAL DIAGNOSIS

Equinovarus: congenital clubfoot, poliomyelitis or other flaccid weakness/paralysis, spastic hemiplegia

Equinovalgus: congenital vertical talus, spastic diplegia or quadriplegia, tarsal coalition, flexible flatfoot with tight tendo Achilles

Cavovarus: hereditary motor and sensory neuropathies, poliomyelitis or other flaccid weakness/paralysis, myelomeningocele

 

 

NONOPERATIVE MANAGEMENT

 

The goals of nonoperative treatment are to achieve and/or maintain mobility and normal alignment. The specific treatments are based on the underlying disease process.

 

 

Options include physical therapy, injection of botulinum A toxin, serial casting, and orthoses. Physical therapy is directed toward improving range of motion and improving strength.

 

Serial casting may help to improve range of motion.

 

Botulinum toxin injections result in a chemical denervation of the muscle group lasting for 3 to 8 months. Botox has been used most frequently in patients with cerebral palsy to decrease spasticity and reduce dynamic muscle imbalance. Such treatment may prevent or delay the need for surgical intervention in patients with spastic equinovarus or equinovalgus.

 

 

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Orthoses may be used to maintain alignment during ambulation or as a nighttime splint to prevent the

development of contractures. The deformity should be passively correctable. Foot orthoses such as the University of California Biomechanics Laboratory (UCBL) may help to control varus/valgus alignment of the hindfoot during ambulation. An ankle-foot orthosis improves prepositioning of the foot during swing phase, provides stability during stance phase, and can be used as a night splint.

 

SURGICAL MANAGEMENT

 

Surgical treatment is offered when nonoperative measures have failed to alleviate the symptoms. Triple arthrodesis is a salvage procedure or “last resort” for rigid deformities in older patients, many of whom have been previously treated by both nonoperative and operative strategies.

 

The procedure often requires removal of bony wedges. As such, careful preoperative planning is required to determine the appropriate size and location of these wedges. Triple arthrodesis shortens the foot, which may be cosmetically objectionable especially when the deformity is unilateral.

 

Arthrodesis transfers additional stresses to neighboring joints, which may result in degenerative changes and pain. Although there are reports of the procedure being successful in children as young as 8 years of age, it has been suggested that surgery should be delayed until the foot has reached adult proportions. One recent

 

study concluded that growth rates were no different in those children treated before or after 11 years of age.14 The deformity should be of sufficient severity that soft tissue releases and osteotomies would be unlikely to

achieve correction or when painful degenerative changes are observed in the joints of the hindfoot. Indications include the recurrent or neglected clubfoot, cavovarus associated with Charcot-Marie-Tooth disease, and severe equinovalgus deformities in patients with spastic diplegia.

 

The goal of surgery is to achieve a plantigrade foot by restoring the anatomic relationships between the affected bones and/or regions of the foot and to relieve pain.

 

Additional procedures may be required. An equinus deformity of the ankle will require a lengthening of the tendo Achilles at the time of triple arthrodesis. In patients with neuromuscular diseases, lengthening or transfer of tendons may be required to restore muscle balance and prevent further deformity. Recurrence of deformity

may occur when coexisting muscle imbalance has not been treated.4, 27

 

 

 

FIG 1 • The lateral approach is used most frequently. A. The skin incision extends from distal to the fibular malleolus across the sinus tarsi. B. All three joints can be visualized after dissection of the subcutaneous tissues, elevation of the extensor digitorum brevis off the anterior process of the calcaneus, and opening of the joint capsules. C. Placement of a laminar spreader may facilitate visualization of the posterior facet of the subtalar joint.

 

 

A hindfoot arthrodesis should be avoided in patients with insensate feet, such as myelomeningocele.

 

Although triple arthrodesis has been performed without fixation, or with minimal fixation such as Kirschner wires or staples, fixation with staples or screws reduces the chances of correction loss and pseudarthrosis.

 

Biomechanical studies have demonstrated no significant difference in stability when comparing fixation with staples versus cannulated screws.17, 18

Preoperative Planning

 

Weight-bearing radiographs are used to evaluate the relationships between the tarsal bones, to identify any morphologic abnormalities and/or degenerative changes, and to identify the location of the deformity. These radiographs help to plan the location of wedge resections.

 

Positioning

 

The patient is placed in the supine position.

 

Approach

 

Several skin incisions have been described for triple arthrodesis, and the specific choice depends on the type of deformity and the previous experience of the surgeon. These include the single lateral or anterolateral approach, the medial approach, and a combined lateral and medial approach.

 

The lateral approach (Ollier) is used in triple arthrodesis for neglected clubfoot (FIG 1).

 

A medial approach has been used for the calcaneovalgus foot, especially if previous incision or surgery has

made lateral aspect tenuous.

 

The Lambrinudi procedure is used for severe equinus deformity. A double-incision approach is used to do triple arthrodesis when no significant deformity is present.

 

 

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TECHNIQUES

• Triple Arthrodesis for the Neglected Clubfoot (Modified Lambrinudi Procedure)

There are several unique features associated with the neglected clubfoot in adolescents which require special attention when performing a triple arthrodesis.8, 20

A lengthening of the tendo Achilles is required and is performed as the first step.

The main components are hindfoot equinus and varus, midfoot cavus, and forefoot adduction.

In contrast to other equinovarus deformities, there is always significant obliquity of the calcaneocuboid joint, which requires a specially oriented lateral wedge excision of that joint.

The foot is typically severely plantarflexed and this component of the deformity comes from both hindfoot equinus and midfoot cavus.

An aggressive resection of the talar head is commonly required to correct the midfoot cavus and bring the forepart of the foot to a plantigrade position.

The skin incision is started 1 cm distal to tip of fibula. It is curved dorsolaterally and extends to the lateral border of talonavicular joint.

After spreading the subcutaneous tissues, the extensor tendons are retracted medially and the sural nerve and peroneal tendons are mobilized and protected (TECH FIG 1).

The extensor digitorum brevis is elevated off its origin and reflected distally, exposing the sinus tarsi, the calcaneocuboid joint, and the lateral aspect of the talonavicular joint.

Soft tissues are cleared from the sinus tarsi, which promotes visualization of the facets of subtalar joint. The anterior and middle facets will be confluent in a subset of cases.

The first step of the procedure is a calcaneocuboid resection. This involves removing a lateral wedge to shorten the lateral border of the foot (TECH FIGS 2 and 3A). One unique feature of the neglected clubfoot is the obliquity at the calcaneocuboid joint. An osteotome or oscillating saw is used to make a cut transverse to the long axis of the calcaneus. The second cut removes the joint surface of the cuboid and should be conservative (several millimeters). The majority of this wedge resection comes from the calcaneus.

The second step involves resecting a portion of the head and neck of the talus (TECH FIG 3B). The cut begins at the superior margin of the articular surface of the talus and extends in a proximal and plantar direction through the inferior portion of the talar neck. This cut is oriented perpendicular to the long axis of the tibia. This essentially removes the entire talar head and a portion of the talar neck.

The third step (TECH FIG 3C) completes the wedge resection and lies along the anterior surface of the calcaneus, parallel to long axis of forefoot in sagittal plane. Completion of this sagittal-oriented wedge resection facilitates dorsiflexion of the forepart of the foot in order to achieve a plantigrade position (correction of midfoot cavus).

The fourth step involves a conservative resection of the articular surface of navicular. A notch is made in the inferior articular surface of navicular to accept the anterior portion of the talus.

With the surfaces of talus and calcaneus apposed, the anterior end of talus is pushed into the notch

under the navicular while abducting the forefoot (TECH FIG 3D).

 

 

 

TECH FIG 1 • Lateral exposure. (From Penny JN. The neglected clubfoot. Tech Orthop 2005;7:19-24.)

 

 

 

TECH FIG 2 • A. The bony segments are removed to correct the neglected clubfoot. B. Conservative resection is shown in blue.

 

 

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With forefoot abduction, heel varus usually corrects. It is not usually necessary to cut lateral-based wedge to correct heel varus.

 

Fixation of the joints is achieved with Kirschner wires, staples, or screws (TECH FIG 3E).

 

 

 

TECH FIG 3 • A. Wedge resection of the calcaneocuboid joint. B. Wedge resection of the anterior process of the calcaneus. C. Excision of the head and neck of the talus back to the posterior facet of the subtalar joint. D. The anterior talus is placed into a notch in the navicular. E. The joint is pinned with the foot in a corrected position. The heel varus corrects with the subtalar joint resection. (From Penny JN. The neglected clubfoot. Tech Orthop 2005;7:19-24.)

• Lambrinudi Triple Arthrodesis

   

  The incision begins 1 cm distal to the tip of the fibula, curves dorsolaterally, and extends to the lateral border of the talonavicular joint.8

   

  The extensor tendons are retracted medially, whereas the peroneal tendons are mobilized and protected. The extensor digitorum brevis is reflected distally, exposing the sinus tarsi, calcaneocuboid joint, and the lateral aspect of the talonavicular joint.

   

  The sinus tarsi is cleared of soft tissue to expose the anterior, middle, and posterior facets of the subtalar joints.

   

  Sequential osteotomies are made with a broad osteotome or power saw (TECH FIG 4A).

   

  The first osteotomy is made along the inferior part of the talus perpendicular to long axis of tibia in both planes.

   

   

   

  TECH FIG 4 • Lambrinudi technique. A. The shaded area represents the bone to be removed. B.

  Realignment of the foot is achieved after removal of bony wedges.

   

   

  The second osteotomy is made along the superior part of calcaneus parallel to the sole of foot in both the longitudinal and transverse planes.

   

  The third cut is made at distal end of calcaneus at right angle to long axis of calcaneus.

   

   

   

  The final cut is made along the proximal end of the cuboid at right angle to longitudinal axis of forefoot. A groove is fashioned in the inferior proximal part of the navicular to accept the anterior end of the talus. The osteotomized surfaces are approximated and held with staples (TECH FIG 4B).

   

   

  The extensor digitorum is lightly sutured back into place, and the subcutaneous tissue and skin edges are reapproximated.

   

• Triple Arthrodesis Using Single Medial Incision

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  A 2-cm longitudinal incision is made over peroneal tendons 10 cm above the level of ankle joint, and both tendons are delivered using a mosquito clamp and divided sharply.13

   

  An 8-cm medial longitudinal incision extends from undersurface of the posterior medial malleolus across the talonavicular joint.

   

  The talonavicular joint is exposed, and the tibialis posterior tendon is released from its insertion. The talonavicular capsule is released. Flexor digitorum longus tendon, flexor hallucis tendon, and neurovascular bundle are protected by retractor.

   

  The talocalcaneal interosseous ligament is divided, and the anterior, middle, and posterior facets of subtalar joint are visualized.

   

  The subtalar and talonavicular joint surfaces are denuded and prepared.

   

  The calcaneocuboid joint capsule and bifurcate ligaments are released sharply, and a lamina spreader is inserted to facilitate removal of the joint surfaces.

   

  Fixation of the subtalar joint is achieved with a single 6.5-mm cannulated screw from the posterior

  calcaneus into the talar body.

   

  The talonavicular and calcaneocuboid joints are realigned and stabilized with 5-mm cannulated screws.

• Beak Triple Arthrodesis for Severe Cavus Deformity

   

  A lateral approach is employed, as outlined in the sections discussed earlier (TECH FIG 5A).24

   

  The articular cartilage of subtalar and calcaneocuboid joints is denuded.

   

  The talar neck is osteotomized from inferior to superior forming a beak superiorly. The soft tissues structures on the superior aspect of the talus anterior to ankle are left undisturbed.

   

   

   

  TECH FIG 5 • Beak triple arthrodesis technique. A. Wedges to be removed. B. Final alignment after correction.

   

   

  The dorsal cortex of the navicular is excised.

   

  The forefoot is displaced plantarward and the navicular is locked beneath the remaining part of the talar head and neck.

   

  Stability can be maintained while plaster is applied by slight upward pressure under the forefoot (TECH FIG 5B). A staple may be used for fixation.

• Inlay Grafting Method for Valgus Deformity

 

This technique obviates the need for a medially based closing wedge osteotomy for valgus deformity of the hindfoot.28

 

An exposure is used, as described previously.

 

The joint surfaces are removed, and the hindfoot is realigned and stabilized with two Kirschner wires.5 An inlay graft is taken from the tibia and placed into a rectangular trough created across the talonavicular, calcaneocuboid, and anterior subtalar joints. The posterior subtalar joint is then denuded and local bone

graft is placed.21

 

A cast is applied, and the Kirschner wires are removed (TECH FIG 6).

 

TECH FIG 6 • Modified Williams and Menelaus' inlay grafting technique.

 

 

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PEARLS AND PITFALLS

 

 

POSTOPERATIVE CARE

The limb is typically immobilized in a short- or long-leg cast for at least 6 weeks, and weight bearing is permitted after 6 weeks.

An ankle-foot orthosis may be required in patients with a neuromuscular diagnosis.

 

 

OUTCOMES

Most studies have included mixed populations. With both children and adults, a variety of diagnoses at early to mid-range follow-up, and variable objective and subjective criteria to assess outcome, it is difficult to draw entirely accurate conclusions. Overall though, successful results have been reported in the

majority of patients, with patient satisfaction in the range of 50% to 95%.7, 22, 23, 26 Rates of union are 89% to 95%.10, 13, 23 In general, poor outcomes have been associated with residual deformity and/or

 

Preoperative

planning

• Weight-bearing radiographs should always be obtained.

Soft tissue

handling

• Gentle soft tissue handling should limit the incidence of wound

complications.

Bone graft

• Local bone graft is sufficient.

Screw fixation of

the subtalar joint

• Placing the screw from the calcaneus into the talus (rather than vice

versa) may decrease incidence of avascular necrosis.

 

 

 

pseudarthrosis. Outcomes seem to be similar when comparing children and adults. The results vary somewhat based on the underlying diagnosis and to deteriorate with longer term follow-up.

The majority of patients have difficulty walking on uneven surfaces. Instrumented motion analysis studies have revealed an increase in ipsilateral knee flexion during stance phase (including push-off) and a loss of ankle plantarflexion during push-off.2, 29 Power generation at the ankle is decreased up to 45%.2, 29

Degenerative changes are common in the surrounding joints at long-term follow-up, but do not imply the presence of pain or a deterioration in results. Chronic pain is seen in a subset of cases.

In cerebral palsy, Ireland and Hoffer12 found excellent results in all patients at 4.5-year follow-up. Tenuta

et al25 found that 80% of patients were satisfied at 18 years follow-up, although 25% had occasional pain and 14% had persistent pain. Lack of satisfaction was correlated with residual deformity and/or pain.

The results in patients with cavovarus feet due to Charcot-Marie-Tooth are less predictable. At 12-year follow-up, Wukich and Bowen30 observed excellent/good results in 88%, with 15% pseudarthrosis and

degenerative changes in 64%. At 21-year follow-up, Wetmore and Drennan27 found excellent or good results in only 24%, with recurrence in nearly 50% because of progressive weakness/muscle imbalance. Twenty percent required conversion to a pantalar arthrodesis for ankle pain associated with degenerative changes.

With flaccid neuromuscular imbalance (polio), the results have been adequate in most patients, provided

that adequate muscle balance has been achieved in addition to the arthrodesis.4 Crego and McCarroll4 found recurrence in 20% of patients, mostly due to persistent muscle imbalance.

 

 

COMPLICATIONS

Injury to neurovascular or tendinous structures. The medial neurovascular bundle and flexor hallucis longus tendon must be protected during resection of posterior facet of the subtalar joint

Wound infection

Wound breakdown or skin necrosis

Pseudarthrosis of one or more joints (6% to 23%), most commonly the talonavicular3, 6, 8, 9, 11, 15, 16, 19,

22, 23, 27, 28

 

Residual deformity

Recurrent deformity may be observed in patients with progressive neuromuscular disease (Charcot-Marie-Tooth) or persistent muscle imbalance (polio, cerebral palsy).4, 27

Degenerative changes are commonly observed at longer term follow-up (longest study is 44 years) and result from increased stress transmission to the neighboring joints. These changes may be observed in both the midfoot (54% to 99%1, 22, 30) and/or the ankle joint (24% to 100% at 44 years22, 25, 30).

Pain from persistent malalignment, degenerative changes, or avascular necrosis of the talus Difficulties with shoe wear

Need for orthotic support or an assistive device for ambulation

 

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3. Bernau A. Long-term results following Lambrinudi triple arthrodesis. J Bone Joint Surg Am 1977;59(4):473-479.

    

    

4. Crego CH, McCarroll HR. Recurrent deformities in stabilized paralytic feet. A report of 1100 consecutive stabilizations in poliomyelitis. J Bone Joint Surg Am 1938;20(3):609-620.

    

    

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