Triple Arthrodesis

Question 1

What is a triple arthrodesis

Answer 1

Fusion of the talocalcaneal joint aka STJ, Talonavicular joint and calcaneocuboid joint (ie rearfoot joints)

Question 2

Which of the 3 joints originally fused in a triple arthrodesis isn’t fused anymore

Answer 2

Calcaneocuboid joint

Question 3

How does triple arthrodesis improve foot function

Answer 3

By providing:
- stability
- correction of deformity
- elimination of pain

Question 4

How many degrees is the normal ROM of the STJ

Answer 4

30 degrees

Question 5

How much inversion is normally in the STJ

Answer 5

20 degrees

Question 6

How many eversion is usually in the STJ

Answer 6

10 degrees

Question 7

Which two joints in the rearfoot act as a unit biomechanically

Answer 7

CC and TN

Question 8

How many pronation and supination does the CC and TN produce

Answer 8

CC - 17 degrees
TN - 7.3 degrees

Question 9

How much dorsiflexion and plantar flexion foes the CC and TN produce

Answer 9

CC - 2.3 degrees
TN - 7 degrees

Question 10

How much range does the CC and TN provide in the oblique axis

Answer 10

22 degrees

Question 11

How much range does the CC and TN provide in the longitudinal axis

Answer 11

8 degrees

Question 12

After a TN arthrodesis, how how much motion is lost in the STJ

Answer 12

92%

Question 13

After a TN arthrodesis, how much motion is loss in the CCJ

Answer 13

97%

Question 14

After a TN arthrodesis, how much PT excursion is retained

Answer 14

25%

Question 15

After an STJ arthrodesis, how much motion is loss in the TNJ

Answer 15

74%

Question 16

After a STJ Arthrodesis, how much motion is loss in CCJ

Answer 16

44%

Question 17

After STJ arthrodesis, how much PT excursion is retained

Answer 17

46%

Question 18

After CCJ Arthrodesis, how much motion is loss in the STJ

Answer 18

8%

Question 19

After CCJ arthrodesis, how much motion is loss in the TNJ?

Answer 19

33%

Question 20

After CCJ arthrodesis, how much PT excursion is retained

Answer 20

73%

Question 21

After a double arthrodesis (TN/CC) how much motion is loss in the STJ

Answer 21

91%

Question 22

After double arthrodesis (TN/CC), how much PT excursion is retained

Answer 22

25%

Question 23

What is the famous article by Donna Astion in JBJS?

Answer 23

Motion of the Hindfoot after Stimulated Arthrodesis

Question 24

What are the indications for triple arthrodesis

Answer 24

• valgus foot deformities
• arthritic conditions
• varus foot deformities
• neuromuscular disease
• joint instability

Question 25

What are the valgus foot deformities requiring triple arthrodesis

Answer 25

- collapsing pets planovalgus - end stage - tibialis posterior tendon dysfunction - end stage - tarsal coalition

Question 26

What are the arthritic conditions that are indications for triple arthrodesis

Answer 26

- RA - Degenerative arthritis - post-traumatic arthritis - chronic pain

Question 27

What varus foot deformities are indications for triple arthrodesis

Answer 27

- cavus and cavovarus - fixed or end stage - talipes equinovarus

Question 28

What neuromuscular disease are indications for triple arthrodesis

Answer 28

- Paralytic - CP - Charcot’s arthropathy - Diseases affecting the spinal cord and brain

Question 29

What are the contraindications for triple arthrodesis

Answer 29

- conditions that can’t be adequately correlated and maintained via eternal brain, soft-tissue procedures, tendon balancing, lesser fusions/osteotomy Ess. - chronic smoking - infection - vascular compromise

Question 30

Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis?

Answer 30

Smokers have twice the risk of experiencing a non-union after fracture etc

Question 31

What are the goals of triple arthrodesis

Answer 31

- correction of deformity - relief of pain ** - stabilization - improved function **

Question 32

What is the clinical test for flexible/rigid cavus foot

Answer 32

Coleman block test - if hindfoot rotates out of varus = flexible - if hindfoot remains in varus = rigid

Question 33

What is the saltzman view on imaging used for

Answer 33

- check for deltoid insufficiency - possible stage IV PTTD

Question 34

What is diagnostic local intra-articulate anesthetic blocks

Answer 34

One of the most reliable office procedures for isolating joint pain from other pain generators

Question 35

Which joints are more difficult to inject die diagnostic local anesthesia blocks

Answer 35

- TN and CC

Question 36

What are STJ injections performed through

Answer 36

sinus tarsi

Question 37

During the surgical treatment for triple arthrodesis, what 2 incisions are made

Answer 37

Medial and lateral

Question 38

What is the importance of the lateral incision in triple arthrodesis

Answer 38

Provides direct access to subtalar and calcaneocuboid joint

Question 39

What is importance of the medial incision in the surgical treatment for arthrodesis

Answer 39

Provides exposure of the Talonavicular joint as well as access for fixation of the STJ

Question 40

Where is the lateral incision made in triple arthrodesis

Answer 40

Distal tip of lateral malleolus to the base of the 4th MT

Question 41

Where is the medial incision made in triple arthrodesis?

Answer 41

Anterior to the distal tip of the medial malleolus extending dorsomedially toward the naviculocuneiform

Question 42

During internal fixation in triple arthrodesis, which joint is fixed first

Answer 42

STJ

Question 43

Which joint is fixed 2nd then 3rd in internal fixation triple arthrodesis

Answer 43

TN, then CC

Question 44

In internal fixation triple arthrodesis, what position can the heel be placed in

Answer 44

Neutral or slight valgus

Question 45

In internal fixation triple arthrodesis, what position should you never leave the heel in and why?

Answer 45

Varus - cannot be accolade by shoe or orthosis

Question 46

What is STJ screw positioning for triple arthrodesis internal fixation?

Answer 46

- 2 screws vs 1 screw - talus to calcaneus, calcaneus to talus - parallel or divergent

Question 47

TN screw positioning for triple arthrodesis internal fixation

Answer 47

2 screws vs 3 screws Addition of staple or plate

Question 48

What is CC screw positioning for triple arthrodesis internal fixation

Answer 48

- plate - staple - 1 vs 2 screws

Question 49

What is phase 1 of post operative management in triple arthrodesis

Answer 49

- initial management - 0-5 days - incision protection - IVAC vs drain vs special dressing - dressing change several days later to evaluate the wound

Question 50

What is phase II of post op management of triple arthrodesis

Answer 50

- consolidation - 5 days to 4 weeks - observe wound healing and resolution of the inflammatory response - NWB in CAM or cast/splint

Question 51

What is phase III of post op management of triple arthrodesis

Answer 51

- radiographs are observed to assess osseous healing - 4 - 8 weeks - AROM exercises of foot, ankle, toes - Patient is maintained NWB

Question 52

What is phase IV of post op management of triple arthrodesis

Answer 52

- 10 - 12 weeks - radiographs taken again - if good consolidation then may begin partial WB with crutches or walker

Question 53

What is phase V of post op management of triple arthrodesis

Answer 53

- 3-6 months - at the 3 months the patient is ready to fully WB with high top basketball shoe

Question 54

What are the complications of triple arthrodesis

Answer 54

- pseudoarthrosis - recurrence of deformity - degenerative arthrosis in adjacent joint - AVN of talus - lateral instability - deltoid instability

Question 55

The complication, pseudoarthrosis, in triple arthrodesis is most common in which joint

Answer 55

TN joint

Question 56

What is the recurrence of deformity in triple arthrodesis

Answer 56

12-62%

Question 57

The complication, degenerative arthrosis, in triple arthrodesis affects with adjacent joint

Answer 57

Ankle joint