High-yield overview

Lateral (Ollier) + medial incisions | subtalar + talonavicular + calcaneocuboid fusion | intermediate

Surgical Imaging

Imaging Gallery

Multi-panel composite showing pre-op foot X-rays CT MRI and post-operative wound after triple arthrodesis — Triple arthrodesis for hindfoot arthritis: nine-panel composite showing the assessment and outcome of hindfoot arthrodesis in Müller-Weiss syndrome. Top row: AP and weight-bearing foot X-rays and coronal CT/MRI images demonstrating hindfoot collapse and arthritis. Middle row: post-operative X-rays showing internal fixation (screws spanning subtalar, talonavicular, and calcaneocuboid joints). Bottom right: clinical lateral view of the foot showing the post-operative wound with staple closure.Credit: Wang X et al. J Med Case Rep 2012; Open-i NIH (PMC3459784) (CC BY PMC Open Access)

Multi-panel showing flatfoot clinical photos with ankle X-ray MRI and post-operative hardware after triple arthrodesis — Triple arthrodesis with plates and screws — pre-operative deformity and fixation: composite image showing clinical evaluation (bilateral weight-bearing foot photographs demonstrating flatfoot deformity and hindfoot valgus), AP ankle radiograph and sagittal MRI images showing the extent of hindfoot arthritis and talar deformity, and post-operative radiographs showing internal fixation spanning the three hindfoot articulations.Credit: Wang X et al. J Med Case Rep 2012; Open-i NIH (PMC3459784) (CC BY PMC Open Access)

Critical Danger Structures

Danger 1: Sural Nerve

Sural nerve. Location: Runs posterior to the peroneal tendons along the lateral border of the foot, typically within 1 cm of the calcaneocuboid joint line. Vulnerable during the lateral (Ollier) approach when deepening between peroneal tendons and extensor digitorum brevis. Protection: Identify and retract posteriorly before joint exposure. Injury causes permanent lateral foot numbness and may generate a painful neuroma overlying the lateral incision.

Danger 2: Dorsal Cutaneous Branches (SPN)

Dorsal cutaneous branches of the superficial peroneal nerve. Location: Fan out dorsally over the midfoot and are at risk during the medial incision used for talonavicular joint exposure. The intermediate dorsal cutaneous branch passes close to the medial incision margin. Protection: Use sharp skin incision only, blunt dissection through subcutaneous fat, and maintain cautious retraction. Injury causes dorsal foot dysaesthesia and painful scar formation.

Danger 3: Dorsalis Pedis Artery

Dorsalis pedis artery and anterior tibial vessels. Location: The dorsalis pedis artery crosses the talonavicular joint on its dorsomedial aspect with accompanying deep peroneal nerve branches. At risk during medial exposure for talonavicular cartilage removal and screw placement. Protection: Identify the artery before deepening medial dissection, retract with a loop, confirm pulsatile flow before closure. Injury causes dorsal foot ischaemia and potentially compromises wound healing.

Danger 4: Wound Breakdown (Lateral)

Lateral wound dehiscence and skin necrosis. Location: The Ollier lateral incision overlies subcutaneous bone with minimal soft tissue padding; blood supply to the lateral hindfoot is tenuous. Risk factors: smoking, diabetes, peripheral vascular disease, excessive skin tension, and aggressive soft-tissue stripping. Protection: Full-thickness skin flaps, minimal soft-tissue devitalisation, avoid excessive tension especially with large deformity corrections; consider staging if skin viability uncertain. Wound breakdown is the leading cause of deep infection and salvage failure.

Danger 5: Valgus/Varus Malposition

Hindfoot malposition at fusion. Location: Not a vascular structure but the most consequential intra-operative hazard. Fusing the heel in greater than 5 degrees valgus causes medial column overload and tibiotalar pain; any degree of varus is catastrophic — it causes lateral foot overload, fifth metatarsal stress fractures, and accelerated ankle arthritis. Assessment: Intra-operative fluoroscopy in AP and lateral views; Saltzman (hindfoot alignment) view; manual assessment of heel alignment relative to tibial axis. Correction: Calcaneal osteotomy if deformity cannot be corrected through joint resection alone.

Mnemonic

STCSTC Fusion — The Three Joints in Order

Mnemonic

FAVEFAVE — Key Steps to Prevent Malposition

Primary Indications

Absolute Indications

Rigid, painful flatfoot deformity (planovalgus) not correctable by soft-tissue procedures alone — typically PTTD Stage III (rigid deformity, passively correctable) or Stage IV (associated ankle valgus)
Rigid cavovarus deformity secondary to Charcot-Marie-Tooth disease, residual clubfoot, or post-poliomyelitis sequelae with documented joint degeneration or intractable lateral column pain
Spastic hindfoot deformity in cerebral palsy or acquired spasticity (stroke, traumatic brain injury) causing a fixed, functionlimiting valgus or equinovalgus foot
Severe, symptomatic hindfoot arthritis across two or more of the three hindfoot joints after failure of conservative management (minimum 3-6 months of orthotics, physiotherapy, and analgesics)

Relative Indications

Failed previous hindfoot surgery (isolated subtalar fusion, calcaneal osteotomy with TN joint arthritis) where further reconstruction is not feasible
Severe symptomatic tarsal coalition with secondary arthritic change in adjacent hindfoot joints
Neuropathic (Charcot) hindfoot deformity — selected stable cases with good bone stock
Painful rigid hindfoot in inflammatory arthropathy (rheumatoid arthritis) where all three joints are involved

Contraindications

Flexible, passively correctable deformity amenable to soft-tissue balancing or isolated joint procedures
Active infection within the surgical field
Severe peripheral vascular disease with inadequate perfusion for wound healing (ABPI < 0.5 or absent palpable dorsal pedis/posterior tibial pulse)
Significant medical comorbidities precluding elective surgery under general or regional anaesthesia
Unrealistic patient expectations regarding residual functional limitation post-fusion — inability to walk on uneven ground, heel-to-toe gait lost

PTTD Staging and Role of Triple Arthrodesis

Stage I: Intact tendon, tenosynovitis only — conservative treatment, tendon debridement if refractory

Stage II: Attenuated or ruptured tendon, flexible deformity passively correctable — lateral column lengthening, medial displacement calcaneal osteotomy + FDL transfer; triple arthrodesis NOT indicated

Stage III: Flexible deformity lost, rigid hindfoot valgus with arthritic change — triple arthrodesis is primary surgical treatment

Stage IV: Stage III plus ankle (tibiotalar) valgus tilt — triple arthrodesis alone insufficient; may require simultaneous or staged deltoid reconstruction or total ankle replacement

Evidence Base

According to PubMed, the following landmark and outcome studies underpin contemporary practice. Each EvidenceCard below has been verified against the primary record.

Long-term Natural History: Angus and Cowell (1986)

Study: Landmark retrospective review of 80 feet followed for a mean of 13 years (published in JBJS Br). Indications were mixed, including paralytic and post-traumatic deformity.

Key Findings:

The majority of patients were subjectively pleased, but objective assessment was less favourable
High incidence of degenerative joint change in the ankle and midfoot
Pseudarthrosis, avascular necrosis of the talus and residual deformity were all recorded
Pre-operative rigid equinovarus deformity accounted for the majority of the poor results
The authors suggested that bony resection alone may be inadequate for correcting severe equinus

Clinical Implication: Triple arthrodesis transfers stress to the ankle and midfoot and carries real risks of pseudarthrosis, talar AVN and residual deformity. Patients must be counselled that subjective satisfaction can mask progressive radiographic adjacent-joint degeneration, and that a rigid equinovarus foot is the highest-risk indication.

Outcomes and the Primacy of Alignment: Pell, Myerson and Schon (2000)

Study: Series of 111 patients (132 feet) followed for a mean of 5.7 years; each underwent triple arthrodesis with rigid screw fixation and realignment of the joint surfaces without wedge resection (published in JBJS Am).

Key Findings:

Overall satisfaction averaged 8.3 out of 10; 91% of patients said they would have the procedure again
Mean postoperative modified AOFAS ankle-hindfoot score was 60.7 points
Radiographic ankle arthritis was significantly more severe postoperatively than pre-operatively
Patient satisfaction was significantly associated with postoperative alignment (p = 0.001), but NOT with the presence of ankle arthritis
Only three non-unions occurred in the whole series, with a low overall complication rate

Clinical Implication: Realignment of joint surfaces without wedge resection gives reproducibly high satisfaction. The single most powerful determinant of a satisfied patient is correct hindfoot alignment, which reinforces the intra-operative priority on heel position over any other technical variable.

Non-union: Patterns and Risk Factors

The talonavicular joint is classically regarded as the most vulnerable site because of its small bony contact area relative to the corrective moment; however per-joint non-union rates vary widely between series and are not uniformly highest at the TN joint in every study (for example, in Graves et al two of three non-unions were calcaneocuboid).
Modern series using rigid internal fixation report low overall non-union rates: Bednarz et al recorded two non-unions in 63 feet, and Pell et al three non-unions in 132 feet.
Risk factors for non-union: smoking, diabetes, corticosteroid use, avascular or sclerotic bone, and inadequate joint-surface preparation (failure to remove the calcified cartilage layer down to bleeding cancellous bone).

Verified Evidence Cards

Triple arthrodesis. A critical long-term review.

Level IV

Angus PD, Cowell HR • J Bone Joint Surg Br

Clinical Implication: Counsel patients that triple arthrodesis transfers stress to the ankle and midfoot, and that bony resection alone may be insufficient for severe equinovarus — the highest-risk indication.

Verify on PubMed (PMID 3958012)

Clinical outcome after primary triple arthrodesis.

Level IV

Pell RF 4th, Myerson MS, Schon LC • J Bone Joint Surg Am

Clinical Implication: Correct hindfoot alignment is the dominant determinant of a satisfied patient — prioritise heel position above all other technical variables, and realign joint surfaces rather than resecting large wedges where possible.

Verify on PubMed (PMID 10653083)

Motion of the hindfoot after simulated arthrodesis.

Level V

Astion DJ, Deland JT, Otis JC, Kenneally S • J Bone Joint Surg Am

Clinical Implication: The talonavicular joint is the biomechanical keystone — its preparation, reduction and fixation determine both the functional result and the corrective power of the whole construct.

Verify on PubMed (PMID 9052546)

Triple arthrodesis in adults using rigid internal fixation: an assessment of outcome.

Level IV

Bednarz PA, Monroe MT, Manoli A 2nd • Foot Ankle Int

Clinical Implication: Rigid internal fixation delivers large, durable functional gains, but malunion and progressive ankle change remain the principal threats — meticulous alignment and selective adjunctive osteotomy or heel-cord lengthening matter.

Verify on PubMed (PMID 10395337)

Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease.

Level IV

Wetmore RS, Drennan JC • J Bone Joint Surg Am

Clinical Implication: In progressive peripheral neuropathy, triple arthrodesis should be reserved as a salvage procedure for severe rigid deformity, with counselling that deformity may recur as the neuropathy advances and that concurrent forefoot balancing is often required.

Verify on PubMed (PMID 2925716)

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 58-year-old woman with a 10-year history of progressive left foot deformity and pain is referred by her GP. She has a rigid flatfoot with heel valgus, abducted forefoot, and uncovering of the talar head. She has tried custom orthotics and physiotherapy for 18 months without benefit. Radiographs show arthritic changes across the subtalar and talonavicular joints. She is otherwise fit. What is your assessment and surgical plan?"

PRACTICAL APPROACH

This presentation is consistent with posterior tibial tendon dysfunction Stage III — rigid, non-correctable flatfoot deformity with established arthritis across at least the subtalar and talonavicular joints. The key clinical point distinguishing Stage III from Stage II is that the deformity is rigid and cannot be passively corrected, making soft-tissue reconstructive procedures (such as FDL tendon transfer and calcaneal osteotomy) inappropriate. With 18 months of failed conservative treatment and radiographic confirmation of arthritis, she meets the criteria for triple arthrodesis. Before confirming the indication, I would examine three additional things: first, the ankle (tibiotalar) joint — if there is ankle valgus tilt on standing radiographs, she may be Stage IV, which requires additional deltoid reconstruction or staged total ankle replacement; second, the neurovascular status of the foot given the planned soft-tissue exposure; and third, her medical comorbidities, particularly diabetes and smoking status, which significantly affect wound healing and union rates. The surgical plan is triple arthrodesis using a dual incision approach — a lateral Ollier incision for the subtalar and calcaneocuboid joints, and a separate medial incision for the talonavicular joint. The lateral approach alone gives inadequate TN joint access in flatfoot deformity where the navicular is abducted. All three joints require meticulous cartilage removal down to bleeding subchondral bone, with multiple drill perforations particularly at the TN joint, which is classically the most vulnerable to non-union. The correction target is 0-5 degrees heel valgus — I would check alignment with fluoroscopy (AP, lateral, and Saltzman hindfoot alignment view) before placing definitive screws. Fixation: two 6.5 mm screws for the subtalar joint, one 6.5 mm screw for the TN joint with rotational control, and one 4.5 mm or 6.5 mm screw for the CC joint. I would counsel the patient that triple arthrodesis provides reliable pain relief and functional improvement — in the Pell, Myerson and Schon series mean satisfaction was 8.3 out of 10 and 91% of patients would have the procedure again — but that progressive ankle and midfoot degeneration is well documented over the long term (Angus and Cowell), driven by transferred stress. Non-weight-bearing for 6 weeks is required, with full weight-bearing expected by 10-12 weeks if union is progressing. She should expect permanent modification of high-impact activities and some difficulty on uneven ground.

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 35-year-old man with Charcot-Marie-Tooth disease presents with bilateral cavovarus feet. He has progressive lateral ankle instability, callosity under the fifth metatarsal heads, and lateral foot pain. Left foot examination reveals rigid hindfoot varus, peroneal weakness, and claw toes. He has tried bracing without benefit. What surgical options exist and how would you approach triple arthrodesis in this case?"

PRACTICAL APPROACH

This is classic CMT-associated cavovarus deformity, and the surgical planning must account for the neurological basis of the deformity. Before planning any hindfoot surgery, I would conduct a comprehensive assessment: detailed neurological examination documenting motor grades (tibialis anterior, peronei, gastrocnemius-soleus, intrinsics), sensory testing, and nerve conduction studies to characterise disease severity and progression. The Coleman block test is essential — it differentiates forefoot-driven from hindfoot-driven varus. If the heel corrects on the Coleman block test, the primary deformity is in the forefoot (plantarflexed first ray) and a dorsal closing wedge first metatarsal osteotomy may correct the hindfoot without fusion. In this case, the description of a rigid hindfoot varus that presumably does not correct on the Coleman block — combined with radiographic evidence of subtalar arthritis and lateral ankle instability — indicates that triple arthrodesis is appropriate. The key technical differences from flatfoot correction are: first, the deformity is in the opposite direction (varus, not valgus), so the bone resection is a medially-based wedge at the subtalar joint to correct heel into valgus; second, the talonavicular joint is plantarflexed and adducted rather than abducted, so access is different; and third, associated peroneal weakness means the fixation must resist varus drift post-operatively. At surgery, using the dual incision approach, I would resect a medially-based wedge from the subtalar joint to swing the heel from varus to 0-5 degrees valgus. The TN joint requires dorsiflexion and abduction to reduce the adducted navicular. Residual forefoot cavus (plantarflexed first ray) after triple arthrodesis requires concurrent first metatarsal dorsal closing wedge osteotomy to prevent the forefoot from driving the hindfoot back into varus. Claw toes may require concurrent proximal interphalangeal joint fusions or flexor-to-extensor transfers. Fixation follows the standard protocol with supplemental bone graft from the resected wedge. Lateral ankle ligament reconstruction (Bröstrom or modified Bröstrom-Gould) is generally deferred until fusion is confirmed solid as the stabilised hindfoot often resolves functional ankle instability, but I would re-assess at 6 months.

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"Walk me through the specific operative steps of triple arthrodesis. What is your fixation strategy for each joint and how do you confirm adequate alignment intra-operatively?"

PRACTICAL APPROACH

I position the patient in lateral decubitus with the operative limb uppermost, ensuring both lateral and medial aspects of the hindfoot are accessible. A thigh tourniquet is essential for a bloodless field. I mark both incisions before inflation — the lateral Ollier incision (from 1.5 cm below the fibular tip to the fourth metatarsal base, approximately 8-10 cm obliquely) and the medial incision (5-6 cm longitudinal over the dorsomedial talonavicular joint). Starting laterally, I make a full-thickness skin incision without undermining — this is critical given the tenuous lateral skin blood supply. I immediately identify and protect the sural nerve posterior to the peroneal tendons with a vessel loop. Peroneal tendons are retracted posteriorly. I detach extensor digitorum brevis from its calcaneal origin and reflect it distally — this exposes the sinus tarsi. The sinus tarsi fat pad is excised to expose the subtalar joint, and the interosseous talocalcaneal ligament is divided to open the posterior facet. I then continue anterolaterally to expose the calcaneocuboid joint. I then make the medial incision, perform blunt dissection through subcutaneous fat to protect dorsal cutaneous nerve branches, identify and retract the dorsalis pedis artery, retract tibialis posterior plantarward, and open the TN joint capsule dorsally. Cartilage removal must be meticulous at all three joints — osteotome and curette to remove all cartilage including the calcified zone, then multiple 2 mm drill perforations through the subchondral plate at each joint, particularly the TN joint. This step determines fusion success. For alignment, I manually position the heel in 0-5 degrees valgus and the forefoot plantigrade, then insert provisional K-wires and obtain fluoroscopy — AP, lateral, and Saltzman hindfoot alignment view. I do not place definitive screws until I am satisfied with the fluoroscopic alignment. Definitive fixation: two 6.5 mm partially-threaded cannulated screws from posterior calcaneus into talar body for the subtalar joint — these are the largest and most important screws providing maximum compression. For the TN joint, one 6.5 mm screw from the navicular tuberosity directed into the talar head, with an optional additional 3.5 mm anti-rotation screw; this joint has the highest non-union rate so secure fixation is paramount. For the calcaneocuboid joint, one 4.5 mm or 6.5 mm screw from calcaneus into cuboid, or a compression staple if bone quality is poor. I confirm final implant position with fluoroscopy, check for joint compression at all three sites, and assess alignment one final time. Before closing I check for haemostasis with the tourniquet deflated, irrigate, and close in layers with full-thickness flaps and monofilament skin sutures without tension.