Dorsolateral Approach to the Talonavicular and Calcaneocuboid Joints

What it exposes. The dorsolateral approach exposes the two components of the Chopart (transverse tarsal) joint - the talonavicular joint dorsomedially and the calcaneocuboid joint laterally. A single incision cannot expose both joints safely, so the strategy uses one dorsal incision (lateral to the tibialis anterior and extensor hallucis longus tendons) to reach the talonavicular joint and a second lateral incision over the calcaneocuboid joint, avoiding a large degloving flap while protecting the named dorsal and lateral neurovascular structures. Why this approach is chosen. The transverse tarsal joint is the functional unit that links the hindfoot to the midfoot and is essential for shock absorption and adaptation to uneven ground. The talonavicular joint lies dorsomedially and the calcaneocuboid joint lies laterally, so two well-spaced incisions expose both joints through healthy skin.

Indications and approach selection Primary indications:

• Triple arthrodesis (subtalar plus talonavicular plus calcaneocuboid fusion) for fixed hindfoot deformity - severe pes planovalgus, cavovarus foot (for example Charcot-Marie-Tooth disease), neglected clubfoot, or post-traumatic hindfoot arthritis
• Double (Chopart) arthrodesis - isolated talonavicular and calcaneocuboid arthritis with a preserved, reducible subtalar joint
• Isolated talonavicular arthrodesis for primary inflammatory or post-traumatic arthritis of the talonavicular joint
• Isolated calcaneocuboid arthrodesis for calcaneocuboid arthritis
• Calcaneonavicular coalition resection in the symptomatic adolescent or young adult (the dorsolateral or sinus tarsi approach is the classic exposure for the coalition bar)
• Open reduction and internal fixation of Chopart (midfoot) fracture-dislocation injuries
• Revision midfoot surgery including non-union exploration and grafting of the Chopart joints

Contraindications:

• Poor soft-tissue envelope over the dorsum or lateral midfoot (blistering, severe contusion, previous incisional compromise)
• Active infection of the surgical field
• Severe peripheral vascular disease, because the dorsalis pedis artery and its tarsal branches are directly at risk and the foot relies on an intact dorsalis pedis contribution in many patients
• Relative - heavy smoking and poorly controlled diabetes increase non-union and wound risk and should be optimised before elective fusion Pre-operative work-up:
• Weight-bearing anteroposterior, lateral and oblique radiographs of the foot and ankle to assess alignment, joint space and deformity
• A computed tomography scan to characterise tarsal coalition, assess bony detail and plan fixation, particularly for complex Chopart injuries
• Magnetic resonance imaging when inflammatory arthritis, osteonecrosis or occult coalition is suspected
• Vascular assessment with palpation of the dorsalis pedis and posterior tibial pulses and, where reduced, Doppler or angiographic evaluation before any fusion that endangers the dorsalis pedis Alternative and complementary approaches:
• Medial approach to the talonavicular joint - an incision over the navicular tuberosity between tibialis anterior and tibialis posterior, used for isolated talonavicular fusion or accessory navicular excision (the Kidner procedure)
• Sinus tarsi (Ollier) approach - the lateral incision extended proximally exposes the subtalar joint and is combined with the dorsal incision for triple arthrodesis
• Anterior approach to the ankle - the dorsal incision extended proximally for combined ankle and Chopart pathology
• Dorsal tarsometatarsal approach - the dorsal incision extended distally when midfoot (Lisfranc) involvement also requires fixation or fusion

Work down through the layers with the patient supine and bumped, opening the talonavicular joint dorsally (lateral to the extensors) and the calcaneocuboid joint laterally (in the peroneal interval), protecting the dorsal neurovascular bundle at every step.

Structures at risk, by layer

Extending the approach:

• Proximally - the dorsal talonavicular incision can be extended proximally along the axis of the long extensors to become the anterior approach to the ankle, useful for combined ankle and Chopart fusion
• Distally - the dorsal incision extends distally onto the dorsum of the midfoot to reach the tarsometatarsal (Lisfranc) joints for extended midfoot fusion or fixation
• Sinus tarsi extension - the lateral calcaneocuboid incision is extended proximally into the sinus tarsi to expose the subtalar joint, which is the key to completing a triple arthrodesis
• Lateral column extension - the lateral incision can be carried distally along the lateral column for lateral tarsometatarsal work Closure and post-operative care:
• Achieve meticulous haemostasis after tourniquet deflation, paying attention to the lateral tarsal and dorsalis pedis branches
• Close the joint capsule over each prepared joint where possible using absorbable suture, and repair the inferior extensor retinaculum carefully to prevent extensor tendon bowstringing
• Close in layers and apply a well-padded posterior splint with the foot in the corrected, plantigrade position
• 0 to 2 weeks - strict non-weight-bearing in a posterior splint, elevation, wound observation, DVT prophylaxis
• 2 weeks - wound check and suture removal, transfer into a non-weight-bearing short leg cast or controlled ankle motion boot
• 6 weeks - weight-bearing radiographs, progress to weight-bearing in a boot if the fusion is consolidating
• 10 to 12 weeks - transition to a normal shoe with a rocker sole if radiographic union is confirmed
• 3 to 6 months - full recovery, footwear modification and orthotic as needed

Guidelines, registries and global practice

Triple and double arthrodesis of the hindfoot and midfoot is performed worldwide, and the surgical principles converge across examination systems. The dorsolateral approach to the Chopart joints is the standard workhorse exposure taught across all of these systems. Weight-bearing radiographs and a CT or MRI for coalition and subtle arthritis are near-universal, and the emphasis on protecting the deep peroneal nerve and dorsalis pedis bundle, on using two well-spaced incisions, and on fusing the hindfoot in slight valgus is shared.

Population and outcome evidence:

• Triple arthrodesis reliably relieves pain and corrects deformity, but long follow-up shows radiographic degenerative change in adjacent joints (the ankle and the naviculocuneiform joints) in a substantial proportion of patients, even when they remain functionally satisfied.
• Calcaneonavicular coalition resection with fat or muscle interposition gives good pain relief and a low recurrence rate compared with resection alone. Global practice variation: In high-resource settings, headless screws, low-profile plates and intra-operative CT are routine and allow early protected weight-bearing. In resource-limited settings the same joints are exposed through the identical dorsolateral incisions and stabilised with large-fragment cancellous or small-fragment screws and staples, with a longer period of cast immobilisation. Consent (globally applicable): discuss wound problems and infection, injury to the deep peroneal nerve and dorsalis pedis with numbness of the first web space, non-union (particularly of the talonavicular joint and especially in smokers), residual or recurrent deformity, and progressive arthritis of adjacent joints over the long term.