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The Use of Arthrodesis to CorrectRigid Flatfoot Deformity

J. Kent Ellington, MDMark S. Myerson, MD

Anatomy andPathophysiologyRigid adult flatfoot deformity (AFD)can evolve over time from a flexibleflatfoot deformity, beginning either inchildhood or acquired later in adultlife, commonly from a rupture of theposterior tibial tendon (PTT). Rigidhindfoot deformity in the adult canalso be the result of trauma, osteoar-thritis, inflammatory arthropathy,neuromuscular imbalance, or neuroar-thropathy. In the child, this deformity

results from various types of tarsal co-alition or a congenital oblique or verti-cal talus. It has been shown that thetriceps surae has the most significantarch flattening effect in the sagittalplane and also contributes largely tothe abduction of the forefoot in thetransverse plane.1,2 As the anatomy ofthe foot changes, the weight-bearingaxis is shifted medially as the hindfootprogresses into more valgus. The cu-mulative increase of force of the tighttriceps results in an increased force

across the arch, which weakens, lead-ing to stretching or tearing of thespring ligament, the PTT, and themidfoot joint capsules.3

As the arch flattens, the talus plan-tar flexes and the calcaneus subluxatesposteriorly. Consequently, the anteriorprocess of the calcaneus does not sup-port the talar head, and the forefootand midfoot rotate dorsally and later-ally around the talus, leading to a lackof coverage of the talus by the navicu-lar. Continued dorsolateral peritalarsubluxation leads to increased stress onthe PTT. Whether a weak PTT leadsto a deformity or is caused by a defor-mity is unclear, although it is knownthat the PTT weakens and may rup-ture through a degenerative process.4

However, flatfoot deformity is notsolely caused by a weak or rupturedPTT. As the talus assumes a moreplantar-flexed position, the spring liga-ment attenuates or ruptures, leading toa nonlinear talar-first metatarsal axis.Although this deformity occurs pre-dominantly at the talonavicular joint,similar subluxation may occur at eitherthe naviculocuneiform or the tarso-metatarsal joints. The plantar-flexedtalus pushes the calcaneus further lat-erally and posteriorly, and the cuboid

Dr. Ellington or an immediate family member has received nonincome support (such as equipment or services),commercially derived honoraria, or other non–research-related funding (such as paid travel) from Smith &Nephew and Wright Medical Technology. Dr. Myerson or an immediate family member has received royaltiesfrom DePuy and Biomet; is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy,Medtronic, and Orthohelix; serves as a paid consultant to or is an employee of DePuy, Biomet, Orthohelix, Torn-ier, and Medtronic; serves as an unpaid consultant to DePuy; has received research or institutional support fromBiomet and Synthes; and has received nonincome support (such as equipment or services), commercially derivedhonoraria, or other non–research-related funding (such as paid travel) from Elsevier.

AbstractRigid adult flatfoot deformity ranges in severity and is caused by a variety of con-ditions. Treatment is based on the etiology, the severity of symptoms, the stage of thedeformity, and patient goals. Posterior tibial tendon pathology, osteoarthritis, post-traumatic arthritis/deformity, inflammatory arthropathy, and neuropathic ar-thropathy are all known causes of adult flatfoot deformity. Regardless of the cause,treatment goals are the same—restore a plantigrade foot, decrease symptoms, andincrease function. When nonsurgical modalities have failed, many surgical recon-structive options are available to restore anatomy and function.

Instr Course Lect 2011;60:311-320.

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slides with the calcaneus, bringingwith it the forefoot and therefore in-creasing abduction. As the deformityprogresses, the calcaneus impingesagainst the fibula, which leads to an-other source of stress and lateral footand ankle pain.5 Combined with allthese described changes, the added de-formity leads to deltoid ligament at-tenuation, causing the ankle to tilt intovalgus.3 It is not clear why a rupture ofthe deltoid ligament develops in someankles but not in others. Based on theexperience of the senior author(MSM), when the talonavicular jointis severely subluxated, the stress on theankle (and hence the deltoid ligament)may be minimized because most of theforce on the medial ankle is directedacross the talonavicular joint. Withmore rigid deformities, the valgus loadon the ankle is greater, and the deltoidis subjected to greater stress and maybe more prone to attenuation or rup-ture.

A rigid deformity implies that thehindfoot cannot be reduced into aneutral position with manual manipu-lation. The degree of rigidity varies; insome instances, there is absolutely nomovement of the subtalar or transversetarsal joint; in others, some flexibilityremains at one of the joints. Also,when manually correcting the heelinto neutral position from valgus,there is a very fixed supination defor-mity of the forefoot. This adaptiveforefoot supination compensates forthe fixed hindfoot valgus because theforefoot has to progressively supinateto maintain a plantigrade position.6,7

This forefoot supination deformitymay be associated with arthritis or in-stability of the first tarsometatarsal orthe naviculocuneiform joint or with afixed elevation of the first metatarsal orthe entire medial column.

Flatfoot rigidity associated with tar-sal coalition, trauma, and arthritides iseasy to explain mechanically. The tran-

sition from a flexible deformity into arigid deformity is poorly understoodbut is likely to represent a gradual me-chanical change resulting from in-creased tension on the triceps suraethat leads to flattening of the arch.1-3

In 1939, Todd8 suggested that thechange from a flexible to a rigid defor-mity was caused by habitual overstrainin patients who are developmentallyweak. In 1948, Lapidus9 stated thetransition was caused by injury to theinterosseous ligament of the subtalarjoint. The long-lasting incongruity ofthe affected joints leads to arthrosis,soft-tissue contractures, and, finally, arigid deformity. It is likely that thegradual attenuation of the medial soft-tissue structures, including the PTT,the spring ligament, and the talonavic-ular capsule, is followed by contractionof the lateral soft tissues, including theperoneal muscles and the interosseousligament. This is followed by adaptivechanges in the periarticular capsulolig-amentous structures, ultimately lead-ing to the rigid deformity.

Patient EvaluationIt is useful to examine the patientwhile he or she is standing and walk-ing. The entire lower extremity shouldbe visible, and the foot should be in-spected from the front, above, and be-hind the patient. With the patientstanding and the examiner viewingfrom behind the patient, the patientshould be asked to stand up on thetoes of both feet and then one foot (adouble- and single-limb heel rise). Pa-tients with a rigid deformity are unableto perform a single-limb heel rise, andeven a double-limb heel rise may beimpossible because of weakness orpain. Regardless of the magnitude ofthe deformity, if the hindfoot is flexi-ble, during the heel rise the hindfootwill transition into varus and the archwill reconstitute. The strength of thePTT is not relevant in the manage-

ment of a rigid deformity, but the loca-tion of pain and tenderness is impor-tant. The range of motion of the ankleand the subtalar, transverse tarsal, andfirst tarsometatarsal joints must beevaluated because each component ofthe deformity, stiffness, and compen-satory motion must be addressed sur-gically. Additional associated featuresof a rigid valgus deformity are subfibu-lar impingement between the tip of thefibula and the lateral margin of the cal-caneus and varying degrees of fixed lat-eral subluxation or abduction of the ta-lonavicular joint, referred to asuncovering of the talar head. In a long-standing deformity, this may lead tocallus formation under the plantar me-dial head of the talus as well as the na-vicular. These fixed articular deformi-ties are in addition to the contractureof the peroneal tendons and the Achil-les or the gastrocnemius muscle. Withrepetitive subfibular impingement, thefibula is compressed; this, in additionto the fixed valgus deformity of thehindfoot, can lead to a stress fractureof the fibula, which is generally ap-proximately 6 cm proximal to the tip.The fibula usually heals in slight val-gus, further perpetuating the valgusdeformity of the hindfoot but now alsopotentially causing a valgus deformityof the ankle joint. Additional medialankle pain can result from stretchingthe tibial nerve and tarsal tunnel syn-drome.

In these patients, it is important toevaluate ankle stability in the coronalplane for both medial and lateral insta-bility. The medial instability isstraightforward and is associated withattenuation or rupture of the deltoidligament. With chronic, rigid, hind-foot valgus deformity, the lateral aspectis compressed against the fibula, whichcan lead to erosion of the calcaneofibu-lar ligament and ultimately to multi-planar coronal plane instability. Thetexture of the skin is important be-

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cause patients with chronic, fixed,hindfoot valgus deformity, particularlythose with any rheumatologic diseaseand any venous stasis, have taut lateralskin. When the foot is corrected fromfixed valgus to a neutral position of thehindfoot, there is marked stretching ofthe lateral skin, which can lead towound dehiscence and infection. If theskin is very taut laterally, it is prefera-ble to use a medial approach to correctthe hindfoot deformity, avoiding anylateral incision.

Weight-bearing radiographs are re-quired, including AP and lateral viewsof the foot, a hindfoot alignment view,and an AP view of the ankle.10 On theAP radiograph of the foot, the talona-vicular coverage, the extent of forefootabduction, and any secondary changesin the midfoot, including arthritisand/or deformity of the tarsometatar-sal and naviculocuneiform joints, areevaluated. On the lateral foot radio-graph, the talometatarsal angle (nor-mal angle, 0° to 10°) and the distanceof the medial cuneiform from the floorshould be measured (normal distance,15 to 25 mm), along with careful in-spection for a subtalar coalition andany changes of the talonavicular joint,such as talar beaking. The oblique footradiograph also should be inspectedfor a calcaneonavicular coalition,which can lead to a rigid deformity.The ankle series should be evaluatedfor any valgus tilt in the tibiotalarjoint. Fluoroscopic examination is use-ful to evaluate the mobility and stabil-ity of the ankle joint, particularly in apatient with a valgus deformity of theankle with or without associated ar-thritis. It is important to determine ifthe ankle valgus deformity is passivelycorrectable because this may deter-mine the type of surgery needed; ideal-ly, this examination should be per-formed fluoroscopically. MRI has novalue in preoperative planning, unlesssevere osteonecrosis of the talus is pres-

ent and associated with a rigid ankleand hindfoot deformity. A CT scanmay be useful to determine the align-ment of the calcaneus relative to the ta-lus and confirm the extent of peritalarsubluxation as well as fracture of thesustentaculum, which occurs in severecases of peritalar subluxation. Thesescans are rarely taken with any weightor pressure on the subtalar joint andshould be carefully interpreted.11

ClassificationIn 1989, Johnson and Strom12 de-scribed three clinical stages of PTTdysfunction. This classification wasmodified in 1997 by Myerson13 byadding a fourth stage, which is definedas the presence of ankle valgus causedby a rupture of the deltoid ligamentwith or without arthritis of the anklejoint. The classification of flatfoot de-formity was further refined by Blumanet al14 in 2007. In the Myerson classifi-cation, although stage III is still char-acterized by rigid hindfoot valgus, it isfurther defined by the presence of fore-foot abduction. In stage IIIA, the de-formity is corrected by a triple arthro-desis. In stage IIIB, the forefootabduction is so severe that to correctthe deformity, the triple arthrodesis iscombined with bone graft lengtheningof the calcaneocuboid joint. Addition-al procedures, such as Achilles length-ening, medial cuneiform osteotomy,medial column arthrodesis, andlengthening or transfer of the peronealor anterior tibial tendons, are per-formed as necessary.

TreatmentNonsurgical treatment can be success-ful despite the rigidity of the defor-mity. Although an orthotic arch sup-port cannot correct the fixeddeformity, a soft, multilayered, archsupport may provide relief of the boneprominence of the head of the talus. Ifmore support is required, a custom,

molded, leather, ankle gauntlet re-ferred to as a Baldwin or Arizona braceshould be considered. The brace fitsinto a comfortable shoe and stabilizesthe ankle area and the talocalcaneal,midtarsal, and subtalar joints. It pro-vides medial and lateral stability tominimize sinus tarsi impingement andreduce forefoot motion. The brace im-proves the function of the limb formost patients but does not correct thedeformity, which can progress if thebrace is not worn.

Most patients eventually stop wear-ing the brace and elect surgery to cor-rect the deformity. The goal of surgeryis to provide a plantigrade foot, de-crease pain, and increase function. Be-cause there are many surgical optionsavailable, choosing the procedure(s) tocorrect the deformity is dependent onthe stage of deformity and the patient’sgoals, age, weight considerations (suchas obesity), and the presence of arthri-tis. Usually, a rigid flatfoot deformitymust be treated with an arthrodesis ofsome type, supplemented with osteot-omy and tendon transfer as required. Itis important to recognize the charac-teristics of a deformity that is too stiffor “not flexible enough” to correctwith tendon transfer or osteotomy, thelatter of which is always preferable tomaximize and maintain motion in thehindfoot. If the hindfoot is stiff, ade-quate deformity correction is unlikelywithout arthrodesis, and the option oftendon transfer should not be advocat-ed. The hindfoot can often be manual-ly reduced to neutral; however, this isaccompanied by severe forefoot supi-nation deformity. In some instances,the “feel” of this examination may helpthe examiner determine that arthrode-sis is preferable, has a greater degree ofpredictability, and will adequatelymeet the patient’s needs. Although ar-throdesis is generally used to correct arigid deformity, under certain circum-stances it may also be indicated in a pa-

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tient with a flexible flatfoot. For exam-ple, in an obese patient, a tendontransfer and hindfoot osteotomies havea higher chance of failure. In some pa-tients with severe laxity of the hindfoot(whether associated with generalizedligamentous laxity, hypermobility, or arupture of the spring ligament), a talo-navicular arthrodesis may be a morepredictable procedure.

Several procedures are available fortreating a rigid flatfoot, and should beadded in sequence in a systematic ap-proach commencing with reduction ofthe subtalar joint and then moving dis-tally depending on the presence of ad-ditional deformity. The heel should bereduced to a more physiologic valgus,the subfibular impingement should becorrected, and the medial arch painand deformity eliminated. The surgicaloptions listed in this chapter includethe type of procedure along with a de-scription of the technique and indica-tions. In all cases, equinus should beevaluated, and an Achilles lengtheningprocedure should be performed (gas-trocnemius recession versus tendonAchilles lengthening if appropriate).

Triple ArthrodesisTriple arthrodesis is a very commonprocedure for correcting a rigid flat-foot deformity. The phrase “triple ar-throdesis” was first used by Ryerson15

in 1923. This procedure was tradition-ally performed with joint preparationwithout any internal fixation and witha long-leg plaster cast. By the early1980s, there was less reliance on castimmobilization and various types ofmore rigid internal fixation becamemore commonly used for correction.With these changes in fixation meth-ods, there was a marked increase in therate of union, but there were also po-tential disadvantages, including an in-crease in varus malunion from overcor-recting the talonavicular joint.16

Although the surgical goal is to create a

functional plantigrade foot, preservingmotion is also important. In some in-stances, a modification of the triple ar-throdesis procedure is used on thehindfoot joints, such as a talonavicularand subtalar arthrodesis or a subtalarand calcaneocuboid arthrodesis. Thisapproach must be carefully consideredbecause a single or double arthrodesiscannot correct deformity as reliably asa triple arthrodesis. Although the ap-proach to the procedure may havechanged over the decades, triple ar-throdesis has remained a standard forcorrecting severe deformity regardlessof the etiology.

Surgical ApproachesSingle-Incision Lateral ApproachThe traditional triple arthrodesis wasoriginally performed through a single-incision lateral approach through thesinus tarsi, but the incidence of com-plications, including persistent defor-mity and nonunion, was commonwith this approach because of limitedvisualization of the talonavicular joint.A cadaver model evaluating prepara-tion of the three joints using the singlelateral approach showed that the carti-lage can be successfully removed in90% of the calcaneocuboid joint, 80%of the subtalar joint, but only 38% ofthe talonavicular joint. Additional re-ported complications included obliter-ation of the talonavicular joint, inad-vertent division of the talar neck ortalar head, removal of excess bone, me-dial skin punctures, and an iatrogeniccut through the talar dome.17 Over thepast two decades, the two-incisiontechnique has become far more popu-lar because it allows the surgeon to bet-ter visualize the adequate preparation,reduction, and alignment of the joints.

Two-Incision ApproachWith the patient supine, a lateral inci-sion is made, extending from the tip ofthe fibula to the base of the fourth

metatarsal. The sural nerve is retractedplantarly, the peroneal tendons areprotected, and the extensor digitorumbrevis is elevated dorsally and pre-served. The sinus tarsi is opened, dé-brided, and distracted with a laminarspreader to visualize the subtalar joint.Care must be taken to remove all thecartilage from the entire posterior,middle, and anterior facets, followedby perforation of the subchondralplate with systematic drilling of boththe talus and the calcaneus with a2.0-mm drill bit at 2-mm intervals,generating abundant bone slurry. A5-mm, curved osteotome is then usedto shingle the joint surfaces to furthergenerate a good cancellous bed ofbone. The calcaneocuboid joint is pre-pared in a similar manner. Next, a dor-somedial incision just medial to theanterior tibial tendon is made. Thisjoint is much more difficult to visual-ize, and although a laminar spreadercan be used to try to twist open thejoint for distraction, the talar bonequality may be poor, causing the headof the talus to be crushed by thespreader. It may be easier to use a pindistractor to open the joint, which isthen prepared as previously described,along with drill holes, which are par-ticularly important if the navicular issclerotic. It is essential to preserve thebone on both joint surfaces, maintain-ing the contour of the talonavicularjoint. If bone is inadvertently removed,the medial column of the foot willshorten, followed by a varus malunion.

The sequence of fixation is subjec-tive, but this chapter’s authors believethat the talonavicular joint should befixed first because this joint functionsas the hinge to the hindfoot. If the de-formity is mild to moderate, the talo-navicular joint is always corrected first,followed by the subtalar joint, which“falls into place.” With the talonavicu-lar joint held reduced, the first ray isplantar flexed by dorsiflexing the hal-

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lux, which further corrects the forefootrelative to the hindfoot. If there is acomplete peritalar dislocation, the sub-talar joint is reduced first because it isdifficult to translate the subtalar jointmedially and simultaneously correctheel valgus in these very severe defor-mities. In contrast, if the subtalar jointis reduced first, it is easy to overcorrectthe talonavicular joint; this overcorrec-tion must be avoided to prevent avarus or adductus malunion. Twopoints of fixation of the talonavicularjoint are recommended. This chapter’sauthors use one 5.0-mm screw fromdistal to proximal in compressionmode along with a two-hole lockingcompression plate placed more dorso-laterally. The subtalar joint is fixednext with one 7-mm screw, followedby fixation of the calcaneocuboidjoint. It is useful to notch the side ofthe calcaneus for insertion of the5-mm screw into the calcaneocuboidjoint to prevent splitting the distal cal-caneus. Alternatively, a plate or staplescan be used quite effectively to com-press the calcaneocuboid joint. If a gapis present in the calcaneocuboid jointfollowing correction of pronouncedforefoot abduction, it may be neces-sary to lengthen the lateral columnthrough the calcaneocuboid joint us-ing a structural bone block graft. Theresults of simultaneous triple arthrode-sis and lateral column lengthening arefavorable.18

Single-Incision Medial ApproachVariations of standard triple arthrode-sis have been described for correctingrigid hindfoot deformity, includingmore limited fusions of either the talo-navicular and the subtalar joints or thesubtalar and the calcaneocuboid joints.A single-incision medial approach alsohas been used with a predictable out-come to perform triple arthrodesis inpatients who are at risk for woundhealing complications associated with

correcting a hindfoot valgus defor-mity.19 This approach can be accom-plished through a rather small incision(Figure 1). Jeng et al19 treated 17 pa-tients with a rigid hindfoot valgus de-formity using triple arthrodesis with asingle medial incision. The indicationfor surgery was refractory pain associ-ated with hindfoot valgus deformitiesin patients with taut lateral skin andpoor skin conditions laterally becauseof contracture. The severity of thehindfoot deformity itself was not theindication for this procedure. A subta-lar and talonavicular arthrodesis wasachieved in all patients and an asymp-tomatic nonunion of the calcaneo-cuboid arthrodesis was reported in 2 of17 patients. In a cadaver study, Jeng etal20 showed that through the singlemedial incision, 91% of the subtalar,91% of the talonavicular, and 90%calcaneocuboid joints could be pre-pared. The medial approach to either atriple or a hindfoot double arthrodesisis a reliable procedure that can be usedin patients with poor-quality lateralskin and a fixed hindfoot valgus defor-mity and in those in whom correctionwith a two-incision approach could

lead to a lateral wound complication.Brilhault21 performed a subtalar andtalonavicular arthrodesis procedure in11 patients and reported the occur-rence of wound healing and arthrode-sis as well as an asymptomatic calcane-ocuboid joint in all patients. Moreimportantly, significant radiographicimprovements were reported in the APtalonavicular coverage angle (from38.5° to 7°), the lateral talonavicular–first metatarsal angle (from 21° to 0°),and the hindfoot-frontal alignmentangle (from 18° to 7.5°).

As this chapter’s authors gainedmore experience with the medial ap-proach to correct deformity, it becameapparent that the calcaneocuboid jointdoes not always need to be included inthe arthrodesis. More recently, thischapter’s authors have attempted totreat most rigid AFDs with a singlemedial incision, either including thecalcaneocuboid joint or not includingthat joint, depending on the ability tocompletely correct the deformity. Theisolated subtalar and talonavicular ar-throdesis must be performed with cau-tion because inferior subluxation ofthe cuboid relative to the calcaneus

Figure 1 Intraoperative photograph of the medial approach for a triple ar-throdesis to correct a hindfoot deformity.



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may occur, resulting in a fixed rotationof the transverse tarsal joint, which willthen lead to pain under the cuboid andthe base of the fifth metatarsal (Fig-ure 2).

Adjunctive ProceduresFollowing any hindfoot arthrodesis,adjunctive procedures are frequentlynecessary to achieve the desired correc-tion of a plantigrade foot. To some ex-tent, these procedures must beplanned ahead of the triple arthrodesisbecause the incisions may vary slightlyas these additional osteotomies andtendon transfers are performed. With asevere abduction deformity, correctionmay be difficult because of peronealtendon contracture; the tendons canbe lengthened or cut or the peroneusbrevis can be transferred to the per-oneus longus. The latter procedure hasa twofold purpose—to lengthen the

lateral contracted tendon and improvethe plantar-flexion strength of the firstmetatarsal. With very severe inferiorsubluxation of the talus under the na-vicular, there is a contracture of the an-terior tibial tendon, which then ele-vates the first ray even further and addsto the deformity. In some instances,correction of the sagittal alignment ofthe first ray cannot be attained withoutlengthening or a lateral transfer of theanterior tibial tendon. The elevationand/or the anterior tibial tendon mayneed to be released if the desired cor-rection cannot be obtained. Correctingthe medial column alignment in thesagittal plane is essential to the successof a triple arthrodesis because loss ofmedial column support will lead to in-sufficient weight bearing, which forcesthe hindfoot into valgus and createsfurther deformity. As the medial col-umn support fails, even if the talona-

vicular joint is fused, the subtalar jointmust evert to maintain a plantigradefoot. Naviculocuneiform arthrodesis,first tarsometatarsal arthrodesis, or amedial cuneiform opening wedge os-teotomy are correction options deter-mined by the location of the deformityand the instability. If fixed forefoot su-pination is present following the triplearthrodesis, and no arthritis at eitherthe naviculocuneiform or first tarso-metatarsal joints is present, it is prefer-able to maintain as much motion inthese joints as possible, performing therealignment at the level of the medialcuneiform. Although the addition of amedial column arthrodesis to the triplearthrodesis adds to the stiffness of thefoot and the potential for arthritis atthe remaining open medial joint, thesedeformities cannot be ignored. Restor-ing the medial column alignment afternaviculocuneiform arthrodesis may

Figure 2 A, Lateral radiograph ofthe foot after a double arthrodesisshowing subluxation of the cal-caneocuboid joint. B, Photograph ofthe foot after a double arthrodesisshowing subluxation of the cal-caneocuboid joint. C, Photograph ofthe foot after reduction and fixationof the subluxated calcaneocuboidjoint. D, Lateral radiograph of thefoot after reduction and fixation ofthe subluxated calcaneocuboid joint.

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provide a link between stability of themidfoot and alignment of the hind-foot.22

First tarsometatarsal joint arthrode-sis is a reliable technique to stabilizethe medial column and correct fore-foot supination following a triple ar-throdesis, especially in the presence ofarthritis, instability, metatarsus eleva-tus, or hallux valgus. It is important tonote that this joint is very deep, mea-suring up to 30 mm, and failure toprepare the plantar aspect of the jointwill result in an undesirable dorsalmalunion. Fixation is ideally per-formed with two axial compressionscrews, although staples or a plate havebeen successfully used for fixation ofthis joint (Figure 3). In 182 patientstreated with a first tarsometatarsaljoint arthrodesis as a part of an AFDreconstruction or correction of halluxvalgus, no nonunions of the first tarso-metatarsal joint were reported whenthe procedure was performed as part ofthe AFD correction.23

When the hindfoot is fixed in severevalgus, the medial shift of the subtalar

joint in conjunction with the triple ar-throdesis may not be sufficient. Theremay be erosion of the lateral subtalarjoint, and correction cannot adequate-ly be obtained without an additionalmedial translational osteotomy of thecalcaneus. This procedure must beplanned ahead because the incisionmay vary if the osteotomy is per-formed simultaneously, by either ex-tending the sinus tarsi incision posteri-orly or using a second oblique incisiondirectly inferior to the peroneal ten-dons over the calcaneus. Following ex-posure, débridement, and joint prepa-ration of the subtalar joint, theosteotomy is performed and provision-ally fixed with Kirschner wires or guidepins. The screws can extend into thetalus, simultaneously correcting andfixing both the calcaneus osteotomyand the subtalar joint (Figure 4).

Management of theUnstable AnkleThe stability of the ankle should bechecked following fixation of the triplearthrodesis, not only for attenuation or

rupture of the deltoid ligament butalso for lateral ankle instability (partic-ularly for those procedures that areperformed for a severe valgus deform-ity). Chronic valgus impingement be-tween the calcaneus and the fibula maylead to erosion of the calcaneofibularligament and subsequent ankle insta-bility. If lateral ankle instability is pres-ent, it must be stabilized to preventsubsequent ankle arthritis. There is

Figure 3 A, AP preoperative radiograph of a rigid flatfoot with hallux valgus and instability of the first tarsometatarsaljoint. B, Lateral radiograph of a rigid flatfoot with hallux valgus and instability of the first tarsometatarsal joint. C, Postop-erative AP radiograph after a triple arthrodesis and first tarsometatarsal arthrodesis. D, Postoperative lateral radiographof the foot after a triple arthrodesis and first tarsometatarsal arthrodesis.

Figure 4 Photograph showing theability to achieve fixation of both amedial displacement calcaneal os-teotomy and subtalar arthrodesis.



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never sufficient tissue present to per-form a simple reconstruction using aBroström-type procedure; therefore,some reconstruction using the pero-neal tendon is preferable. This chap-ter’s authors use a modified Chrisman-Snook procedure.24 A rupture of thedeltoid (stage IV deformity) can becorrected in a variety of ways. The an-kle must be examined to determine ifthe deformity is passively correct-able (stage IV-A) or if it is rigid(stage IV-B). Fluoroscopic examina-tion at the time of the triple arthrode-sis is helpful, but it is preferable to per-form it ahead of time to anticipate theplanned procedure (Figure 5). In stageIV-B deformity or if the ankle defor-mity is flexible but associated with ar-thritis, it should be corrected with ei-ther a tibiotalocalcaneal arthrodesis ora pantalar arthrodesis. Total ankle re-placement in this setting is highly un-reliable, and a fixed valgus deformityof the ankle is best treated with arthro-desis. The use of an intramedullary rodis preferred for primary and revisionarthrodesis, especially in revision sur-geries for correcting a stage IV defor-mity. Although tibiotalocalcaneal andpantalar fusions are successful in ob-taining a plantigrade foot, there can beassociated morbidity. Even after suc-

cessful fusion, the energy expenditureof ambulation is increased, and func-tionality and patient satisfaction aredecreased.25 For managing a stageIV-A deformity, the ankle joint can bepreserved with a variety of ligament re-construction techniques performedfollowing the necessary hindfoot andmidfoot realignment. The correctionof the hindfoot and midfoot alignmentmust be obtained, with particular at-tention to ensuring good, stable align-ment of the medial column; a first tar-sometatarsal arthrodesis should beperformed if necessary. Studies haveshown that a medial translational os-teotomy of the calcaneus is also benefi-cial because it decreases the valgusforce on the deltoid ligament.26 If thestage IV deformity is associated withmalunion of a previously performedhindfoot arthrodesis, then either thecorrection should be made at the anklejoint in stage IV-B deformities or a re-vision arthrodesis should be followedby a deltoid reconstruction.

Deltoid reconstruction falls intothree categories: repair of the ligament,advancement of the ligament, or theuse of a tendon graft (either an au-tograft or an allograft).27-30 The localremnant of the deltoid ligament, PTT,and capsule are not sufficient to main-tain long-term correction, and failureof these approaches has been re-ported.26 This chapter’s authors rec-ommend a technique that uses aforked semitendinosus allograft ten-don in conjunction with soft-tissue in-terference screws to reconstruct thedeep tibiotalar ligaments and the su-perficial calcaneofibular fibers. Thegraft is anchored in a tibial tunnel thatis created parallel to the joint at thelevel of the physeal scar. After a Krac-kow suture is placed in the distal endof the tendon, it is then passed subcu-taneously over the medial malleolus. Atalar tunnel is created, and the tendonis passed, manually tensioned, then se-

cured. Next, a calcaneal tunnel is cre-ated, and the tendon is passed, ten-sioned, then secured.26

ResultsThe results of triple arthrodesis forAFD have been studied extensively. Aseries of 32 triple arthrodeses forstage III and IV deformity (averagefollow-up, 4.3 years) showed improve-ment in American Orthopaedic Footand Ankle Society scores by 36 points,with all but one patient reporting satis-faction with the procedure. There wasone nonunion and two malunions.31

Similarly, in a series of 44 feet (9 withAFD), 34 had good results.32 In astudy of the results of triple arthrodesisin 132 feet (average follow-up,5.7 years), Pell et al33 reported an over-all patient satisfaction score of 8.3 of10. Interestingly, 60% of the patientshad clear radiographic progression ofankle arthritis, but this did not corre-late with patient satisfaction. The lon-gest outcome data available in the liter-ature on triple arthrodesis shows a95% patient satisfaction rate at 40-year follow-up.34

Limited HindfootArthrodesis ProceduresAs previously discussed, an isolated ta-lonavicular arthrodesis cannot correctexcessive hindfoot valgus or instabilityof the midfoot joints. It has beenshown in a cadaver model that isolatedtalonavicular fusion was as powerful asboth the triple and double arthrodesis;however, it reduced hindfoot motionby 80%.35 An isolated talonaviculararthrodesis is occasionally indicatedfor managing rigid flatfoot deformity,but it may be better indicated for se-vere hypermobility associated with arupture of the spring ligament and aflexible flatfoot deformity. The talona-vicular joint is the apex of the deformi-ty in AFD,35 and certainly most of thetransverse tarsal joint deformity and

Figure 5 Fluoroscopic imageshowing an incompetent deltoid af-ter a triple arthrodesis.

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abduction of the midfoot can be cor-rected with an isolated talonaviculararthrodesis. Residual hindfoot valgusremains a concern with this technique,and a medial displacement calcanealosteotomy can be added if necessary tocorrect the heel deformity. At 27-month follow-up, 26 patients withAFD treated with an isolated talona-vicular arthrodesis had favorable out-comes with no pain or pain only afterheavy use. Although the procedure wasperformed for patients with AFD, itwas not reported if the deformity wasflexible or rigid. A successful fusionwas achieved in all the patients and noloss of correction was reported. Mildasymptomatic adjacent joint arthritiswas reported in five patients, and ankleplantarflexion was decreased by10°.36,37

A double arthrodesis (talonavicularand calcaneocuboid joints) has beendescribed with an overall satisfactionrate of 83% with the procedure.38,39

Progressive degeneration of the sur-rounding joints was common, and themost frequent complication was non-union at the talonavicular joint. Theauthors stressed that this procedurewas indicated only in rigid flatfeet inwhich the principle deformity was atthe transverse tarsal joints, with nosubtalar arthritis present.39

Isolated subtalar arthrodesis is aneffective procedure for stage II andsome stage III deformities.40 This ap-proach is recommended only whenmost of the deformity originates fromthe subtalar joint, less than 30% of thetalonavicular joint is uncovered, painis isolated to the lateral foot and sinustarsi, and arthritis is present in the sub-talar joint; it can also be used as a sal-vage procedure for a failed prior recon-struction. A subtalar arthrodesis maybe performed in conjunction with aflexor digitorum longus transfer andsupplemented by a medial columnprocedure as necessary to correct fore-

foot supination and instability. In pa-tients with a somewhat flexible defor-mity that could be treated with tendontransfer and osteotomy, this approachmay provide more durable results, par-ticularly if associated with inflamma-tory arthropathy or obesity. The bene-fit of isolated subtalar fusion is jointpreservation of the transverse tarsaljoint. A cadaver study showed a 39%loss of eversion and a 41% loss of in-version with subtalar arthrodesis, withminimal affect on dorsiflexion andplantarflexion.41 Extending the fusionto a triple arthrodesis showed a 16%reduction in plantarflexion and a 13%decrease in dorsiflexion. The triple ar-throdesis also resulted in an additional20% loss of eversion and 22% loss ofinversion. Studies evaluating isolatedsubtalar arthrodesis for AFD in con-junction with flexor digitorum longustransfer have reported good re-sults.42,43

SummaryThe surgical management of rigidAFD requires a systematic approach. Acareful patient history, a thorough ex-amination, and a detailed review ofweight-bearing radiographs are para-mount in determining the etiologyand the stage of the deformity. Afterthis is achieved, a well-planned surgerycan be devised. Many options exist forsurgical correction. Careful patient se-lection and meticulous technique arerequired for successful outcomes. Re-gardless of the surgical reconstruction,the goal is a long-lasting plantigradefoot.

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