Triple Arthodesis



Able to achieve relatively high level of function after STJ fusion

- previously believed that isolated STJ fusion should not be performed

- believed that triple arthrodesis was operation of choice for hindfoot

- STJ fusion has superior result with less stress on AJ


Average loss of DF 30% / PF 10%


Position of hindfoot determines flexibility of transverse tarsal (CCJ & TNJ) joints

- imperative that fusion be positioned in ~ 5o valgus 

- permits TTJ mobility

- if varus TTJ locked & patient tends to walk on lateral aspect of foot 


Indications for STJ arthrodesis


 Subtalar Arthritis


Post traumatic / calcaneal fracture




Primary OA




Talar Coalition CN 1Calcaneonavicular coalition subtalar OA MRI


Tibialis posterior dysfunction


Neuromuscular disorders

- instability

- CMT / polio / nerve injury


Indication for Triple Arthrodesis


Valgus deformity



Triple Arthrodesis


Technique STJ Fusion


Subtalar ArthrodesisSubtalar Arthrodesis 2





- patient supine

- roll under hip to expose lateral aspect foot

- tourniquet, IV Abx, radiolucent table, II available




1. Tip of fibula toward base of 4th MT (Ollier's)

- internervous plane between SPN and sural nerve


2.  Lateral longitudinal

- required if large correction required

- i.e. post calcaneal fracture

- must insert bone graft and might not be able to close wound


Superficial dissection

- peroneal tendons lifted dorsally

- elevate EBD

- fatty tissue over sinus tarsi

- expose STJ / CCJ / sinus tarsi


Deep dissection

- remove TC interosseous ligament

- clear out sinus tarsi

- diathermy artery of tarsal sinus

- insert lamina spreader to expose posterior facet

- need to expose medial facet medially



- curette / osteotomes / burr

- simply remove cartilage if no deformity

- otherwise remove bone to correct deformity

- recreate 2 flat surfaces that come together in 5o valgus

- drill holes to stimulate bleeding +/- bone graft

- if previous calcaneal fracture lateral wall needs to be decompressed 


Reduction technique in valgus foot



- talus internally rotated on calcaneum

- navicular abducted on talus



- need T Achilles lengthening

- need to perform TNJ and CCJ fusion

- likely need to have open reduced TNJ / CCJ before STJ reduction

- may need lateral bone block

- often deficient skin laterally



- reducing calcaneum back under talus difficult

- calcaneum also abducted like navicular

- lamina spreader between lateral process talus and anterior aspect of calcaneum

- open it up

- calcaneum internally rotates / talus externally rotates

- screw like motion

- need to have all joints opened and exposed for this to occur

- need care to ensure don't place foot into varus




Insert K wires for 6.5 mm cannulated screw


A.  From talar neck (medial) down into calcaneum


B.  Two from inferior calcaneum via stab incisions into body and neck of talus


Check position of K wires on II before screw insertion


Bone graft

- best to do so

- take from proximal lateral tibia near Gerdy's tubercle 


TNJ fusion


Arthrodesis CCJ TNJ



- isolated TNJ OA (lose 80% subtalar joint motion)

- as part of triple arthrodesis


Midfoot Approach



- medial to T anterior, anterior to T posterior

- talar neck to naviculo-cuneiform joint

- protect saphenous nerve and vein

- Tibialis posterior guide to navicular



- can sometimes only expose 2/3 of joint medially

- may need to utilize the lateral approach for full exposure

- inserting lamina spreader aids exposure to debride

- reduce forefoot onto navicular by adducting /plantar flexing and pronating it

- must not leave in varus

- provisionally fix with K wires



- 2 x 4.0 mm cannulated screws

- from navicular into talus

- in parallel

- may need to make notch in medial cuneiform 


CCJ fusion



- continue normal incision anteriorly

- expose anterior process of calcaneum

- expose CCJ



- 2 x screws

- must hug lateral border

- alternatively can use specific plates


T Achilles lengthening



- tight T Achilles

- if don't will have to take a lot of bone to get foot plantigrade



A.  Formal Z lengthen

B.  Hoke lengthening

- want to lengthen laterally more than medially

- 2 incisions halfway laterally

- 1 half incision medially between them

- stretch out the T Achilles