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SECTION IV: Lesser 31 Lapidus Bunionectomy: Metatarsophalangeal Joint First Metatarsal–Cuneiform Arthrodesis ...... 322 Deformities LAWRENCE A. DIDOMENICO AND MARI WARGO-DORSEY 19 Plantar Plate Repair of the Second Metatarsophalangeal Joint ...... 187 32 Juvenile Hallux Abducto Valgus Deformity ...... 331 CRAIG A. CAMASTA DONALD R. GREEN, KIERAN T. MAHAN, AND 20 Transverse Plane Digital TRACY L. KLIMAZ Deformities ...... 202 33 Joint Salvage and Preservation MICHAEL S. DOWNEY, MICHAEL C. MCGLAMRY, Surgical Techniques for AND SARAH A. SPIZZIRRI Hallux Limitus ...... 343 21 The Weil Lesser Metatarsal ANNALISA Y. CO, THOMAS J. CHANG, AND Osteotomy ...... 224 CRAIG A. CAMASTA RICHARD J. ZIRM 34 First Metatarsophalangeal 22 Central Rays: V Osteotomy, DFWO, Joint Arthroplasty ...... 362 Condylectomy ...... 229 JOHN V. VANORE, WILLIAM G. MONTROSS, WILLIAM D. FISHCO AND JEFFREY S. BOBERG A. LOUIS JIMENEZ, AND JONNICA S. DOZIER 23 Tailor’s Bunion Deformity ...... 235 35 First Metatarsophalangeal Joint SEAN PATRICK DUNN AND JANE PONTIOUS Arthrodesis ...... 400 THOMAS F. SMITH AND ALLISON J.A. MENKE PART III: FIRST RAY, HALLUX 36 Complications in Hallux Abducto ABDUCTO VALGUS, AND Valgus Surgery (Excluding Hallux RELATED DEFORMITIES Varus) ...... 417 MOLLY A. JUDGE 24 Evaluation and Procedural Selection in Hallux Valgus Surgery ...... 245 37 Hallux Varus ...... 461 MOLLY A. JUDGE JEFFREY S. BOBERG 25 Anatomic Dissection of the First Metatarsophalangeal Joint for Hallux PART IV: REARFOOT Valgus Surgery ...... 250 JOHN A. RUCH, CHARLES F. PEEBLES, AND SECTION I: Midfoot and Heel CLAIRE A. HOLLSTROM Surgery 26 Hallux Osteotomies ...... 260 THOMAS F. SMITH AND JARED L. MOON 38 Common Pedal Prominences . . . . . 471 27 Distal Metaphyseal Osteotomies in THOMAS F. SMITH AND LESLIE B. DOWLING Hallux Abducto Valgus Surgery . . . 279 39 Plantar Heel ...... 494 THOMAS A. BROSKY II AND PATRICK B. HALL JEFFREY S. BOBERG, DAMIEN M. DAUPHINÉE, 28 Proximal Osteotomies of the First D. SCOT MALAY, AND WILLIAM HARRIS IV Metatarsal ...... 290 40 The Distal Tarsal Tunnel: First ROBB A. MOTHERSHED Branch of the Lateral Plantar Nerve Release ...... 505 29 Offset-V Osteotomy of the First Metatarsal Shaft in Hallux Abducto ROBERT M. GOECKER Valgus ...... 302 41 Plantar Foot Surgery ...... 513 GARY R. BAUER AND HAROLD W. VOGLER J. MICHAEL MILLER AND SUHAIL B. MASADEH 30 Z-Scarf Osteotomy ...... 314 42 Pes Cavus Surgery ...... 525 CHARLES J. GUDAS CRAIG A. CAMASTA AND ANDREA D. CASS

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SECTION II: Valgus Foot 56 Tarsometatarsal Arthrodesis ...... 810 Deformity SHINE JOHN, ALAN R. CATANZARITI, AND ROBERT W. MENDICINO 43 Ankle Equinus ...... 541 57 Trephine Arthrodesis at the MICHAEL S. DOWNEY AND JACLYN M. SCHWARTZ Midfoot ...... 820 44 Flexible Valgus Deformity ...... 585 ANNETTE D. FILIATRAULT KIERAN T. MAHAN AND K. PAUL FLANIGAN 58 Triple Arthrodesis ...... 824 45 Tarsal Coalition ...... 598 JOHN A. RUCH, LOPA DALMIA, AND PATRICK B. HALL MICHAEL S. DOWNEY AND ALISON M. DEWATERS 59 Subtalar Joint Arthrodesis ...... 843 46 Posterior Tibial Tendon MARK A. HARDY Dysfunction ...... 636 ALAN R. CATANZARITI, ROBERT W. MENDICINO, 60 Talonavicular Fusions ...... 851 AND MICHAEL P. MASKILL WILLIAM D. FISHCO 47 Medial Column Fusion ...... 670 61 Pantalar Arthrodesis ...... 855 THOMAS J. CHANG TRAVIS A. MOTLEY AND BRIAN B. CARPENTER 48 Arthroereisis ...... 675 VOLUME TWO DONALD R. GREEN AND MITZI L. WILLIAMS PART VII: SPECIAL SURGERY: PART V: ANKLE CONDITIONS

49 Os Trigonum Surgery ...... 691 SECTION I: Rheumatoid Foot MOLLY A. JUDGE and Ankle 50 Acute Ankle Conditions ...... 702 62 Rheumatoid Rearfoot...... 863 MARK A. HARDY AND GINA A. HILD LINNIE V. RABJOHN AND DANIEL J. YARMEL 51 Old Syndesmotic Injuries ...... 710 63 Pan Metatarsal Head Resection . . . 876 BRIAN B. CARPENTER AND TRAVIS A. MOTLEY DENNIS E. MARTIN 52 Ankle Replacement Arthroplasty . . 717 JOHN M. SCHUBERTH, JEROME K. STECK, SECTION II: Neurologic Disorders AND JEFFREY C. CHRISTENSEN 53 Arthroscopy of the Ankle 64 Spasticity and Paralytic and Foot ...... 757 Disorders ...... 884 JEFFREY C. CHRISTENSEN, MEAGAN M. JENNINGS, R. DAVID WARREN AND JOHN J. STIENSTRA 65 Charcot-Marie-Tooth Disease . . . . . 892 54 Osteochondroses of the Foot ROBERT M. GOECKER, ALAN S. BANKS, and Ankle ...... 780 MICHAEL S. DOWNEY, AND RICHARD J. ZIRM LAWRENCE M. FALLAT, JEFFREY C. CHRISTENSEN, AND SECTION III: Peripheral Nerve JACOB A. HORD Surgery

PART VI: MIDFOOT JOINT 66 General Entrapment Syndromes . . . 912 ARTHRODESIS D. SCOT MALAY, E. DALTON MCGLAMRY, AND MARIJA UGRINICH 55 Principles of Arthrodesis ...... 803 67 Tarsal Tunnel Syndrome ...... 934 SEAN PATRICK DUNN, JUSTIN T. MEYER, MICHAEL S. DOWNEY AND DANIEL J. YARMEL AND JOHN A. RUCH

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68 Complex Regional Pain Syndromes 78 Achilles Tendon Disorders ...... 1181 and Related Disorders ...... 950 JAMES L. THOMAS JEFFREY C. CHRISTENSEN 79 Plastic and Reconstructive Surgery ...... 1193 SECTION IV: Diabetic Foot TOD R. STORM AND MICHAEL S. LEE

69 Evaluation and Management of 80 Bone Anchors ...... 1222 the Diabetic Foot Wound ...... 986 THOMAS A. BROSKY II, MICHAEL C. MCGLAMRY, AND MITZI L. WILLIAMS JOHN S. STEINBERG AND PAUL J. KIM 70 Charcot Foot and Ankle 81 Interpositional Arthroplasty of Deformity ...... 1008 the First Metatarsophalangeal THOMAS M. ZGONIS, JOHN J. STAPLETON, Joint ...... 1231 AND THOMAS S. ROUKIS CHRISTOPHER F. HYER AND JAYMES D. GRANATA 71 Amputations ...... 1022 ROBERT P. TAYLOR, JAMES L. BOUCHARD, 82 Lateral Column Arthroplasty . . . . 1234 AND LINNIE V. RABJOHN THOMAS J. CHANG

SECTION V: Congenital PART IX: SPECIAL SURGERY: Deformities MISCELLANEOUS TOPICS

72 Brachymetatarsia ...... 1036 83 External Fixation of Rearfoot MICHELLE L. BUTTERWORTH AND and Ankle Arthrodeses ...... 1241 DENNIS E. MARTIN BRADLEY M. LAMM 73 Metatarsus Adductus and Allied 84 Puncture Wounds ...... 1254 Disorders ...... 1056 STEPHEN V. COREY AND MICHELLE L. PATRICK S. AGNEW BUTTERWORTH 74 Clubfoot ...... 1079 85 Lower Extremity Infections . . . . . 1267 LUKE D. CICCHINELLI, DAVID J. GRANGER, MARK A. KOSINSKI AND WARREN S. JOSEPH TODD R. GUNZY, TODD B. HADDON, Osteomyelitis ...... 1287 AND JORGE G. PENAGOS VASQUEZ 86 LAWRENCE M. OLOFF AND GEOFFREY S. HEARD 75 Congenital Digital Deformities . . . 1097 75.1 Polydactyly 1097 87 Nonunions ...... 1309 ANNETTE D. FILIATRAULT STEPHAN J. LAPOINTE 75.2 Macrodactyly 1106 88 Orthobiologics ...... 1322 THOMAS A. BROSKY II D. SCOT MALAY AND WILLIAM HARRIS IV 75.3 Ectrodactyly 1109 CORNELIUS M. DONOHUE 89 Electrical and Mechanical 75.4 Syndactyly 1117 Bone Growth Stimulation ...... 1333 CARL R. WAGREICH, RENATO J. GIORGINI, MICHAEL S. DOWNEY AND TARA L. GIORGINI WEN-YIN CHOI WANG 90 Nonosseous Injuries ...... 1350 PART VIII: SPECIAL SURGERY: KEITH D. COOK SOFT TISSUE

76 Principles of Muscle–Tendon PART X: TUMORS Surgery and Tendon Transfers . . . 1127 STEPHEN J. MILLER AND MACK JAY GROVES IV 91 Skin Lesions ...... 1363 77 Peroneal Tendon Disorders . . . . . 1165 D. SCOT MALAY AND MARIJA UGRINICH LAWRENCE A. DIDOMENICO 92 Soft Tissue Masses ...... 1387 AND MICHELLE C. ANANIA MICHAEL S. DOWNEY AND CHRISTA M. GREDLEIN

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93 Bone Tumors of the Foot 104 Metatarsal Fractures ...... 1646 and Ankle ...... 1413 MICHAEL S. LEE AND LINDA HO LAWRENCE S. OSHER, BRYAN D. CALDWELL, 105 Midfoot Fractures ...... 1662 AND HILAREE B. MILLIRON TRAVIS A. MOTLEY AND BRIAN B. CARPENTER 94 Surgical Management of Bone 106 Tarsometatarsal (Lisfranc) Tumors in the Foot and Ankle . . 1474 Joint Dislocation ...... 1677 HILAREE B. MILLIRON, JOSEPH A. FAVAZZO, LAWRENCE A. DIDOMENICO AND AND B. HUDSON BERREY DAWN Y. STEIN 95 Plantar Fibromatosis ...... 1486 107 Calcaneal Fractures ...... 1685 MICHAEL S. DOWNEY AND MEAGAN M. JENNINGS AND RANDALL J. CONTENTO JOHN M. SCHUBERTH 108 Talar Fractures ...... 1707 PART XI: TRAUMA JOHN M. SCHUBERTH, SHANNON M. RUSH, AND MEAGAN M. JENNINGS SECTION I: Acute Trauma 109 Ankle Fractures ...... 1739 LAWRENCE M. FALLAT, THOMAS J. MERRILL, 96 Open Fractures ...... 1499 ZEESHAN S. HUSAIN, AND KITTRA T. OWENS MARK A. HARDY AND JORDAN P. GROSSMAN 110 Pilon Fractures ...... 1765 97 Complex Soft Tissue Injuries: GEORGE S. GUMANN AND JUSTIN J. FLEMING Degloving and Soft Tissue Loss 111 Pediatric Foot and Ankle Injuries ...... 1508 Fractures ...... 1786 RYAN H. FITZGERALD AND JOHN S. STEINBERG EDWIN J. HARRIS 98 Complications of Internal Fixation ...... 1523 SECTION II: Repair of JOHN V. VANORE AND WILLIAM G. MONTROSS Posttraumatic Injuries 99 Trauma to the Nail and Associated Neglected Calcaneal Fractures . . 1835 Structures ...... 1535 112 GEORGE T. LIU D. SCOT MALAY AND ROBYN WINNER 100 Management of Acute and Chronic 113 Ankle Malunions ...... 1849 Tendon Injury ...... 1549 BRADLEY M. LAMM AND JOHN E. HERZENBERG RYAN H. FITZGERALD 114 Supramalleolar Osteotomy . . . . . 1874 101 Achilles Tendon Trauma ...... 1580 SHANNON M. RUSH, AND JOHN M. SCHUBERTH ALAN NG AND KEITH L. JACOBSON 115 Talar Avascular Necrosis ...... 1890 102 Dislocations of the Foot CHRISTOPHER F. HYER AND WILLIAM T. DECARBO and Ankle ...... 1600 GRAHAM A. HAMILTON, LAWRENCE A. FORD, 116 Lisfranc Injuries ...... 1914 AND JOHANNA-MARIE RICHEY GEORGE F. WALLACE 103 Digital and Sesamoid 117 Fibular Lengthening ...... 1924 Fractures ...... 1629 BYRON L. HUTCHINSON MICHAEL S. DOWNEY AND GRETCHEN A. LAWRENCE Index 1929

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Keith D. Cook, DPM, FACFAS Cornelius M. Donohue, DPM Joseph A. Favazzo, DPM Director, Podiatric Medical Education Medical Director, Comprehensive Wound Assistant Professor University Hospital Healing Center Department of Surgery University of Medicine and Dentistry of Roxborough Memorial Hospital Ohio College of Podiatric Medicine New Jersey Philadelphia, Pennsylvania Private Practice Newark, New Jersey Twinsburg, Ohio Leslie B. Dowling, DPM Stephen V. Corey, DPM, FACFAS Faculty Danny R. Fijalkowski, DPM Faculty The Podiatry Institute Center for Podiatric Medicine The Podiatry Institute Decatur, Georgia and Surgery Decatur, Georgia Private Practice Belmont Community Hospital, a Division Private Practice Waycross, Georgia of Wheeling Hospital Pee Dee Foot Clinic Bellaire, Ohio Kingstree, South Carolina Michael S. Downey, DPM, FACFAS Annette D. Filiatrault, DPM, MS, Timothy W. Crislip, DPM Faculty FACFAS Private Practice The Podiatry Institute Faculty Columbia Orthopaedic Group Decatur, Georgia The Podiatry Institute Columbia, Missouri Clinical Professor and Former Chairman, Decatur, Georgia Department of Surgery Private Practice Lopa Dalmia, DPM Temple University School of Atlanta, Georgia Faculty Podiatric Medicine The Podiatry Institute Chief, Division of Podiatric Surgery William D. Fishco, DPM, MS, Decatur, Georgia Penn Presbyterian Medical Center FACFAS Associate Physician, Podiatric Surgery Private Practice Faculty University of California Davis Ankle and Foot Medical Centers of the The Podiatry Institute Health System Delaware Valley Decatur, Georgia Citrus Heights, California Philadelphia, Pennsylvania Teaching Faculty Maricopa Medical Center Damien M. Dauphinée, DPM, Jonnica S. Dozier, DPM Private Practice FACFAS, FAENS, FACCWS, Staff Podiatrist Anthem, Arizona CWS-P Carl Vinson Veterans Administration Medical Director Medical Center Ryan H. Fitzgerald, DPM, Center for Wound Healing and Dublin, Georgia AACFAS Hyperbaric Medicine Private Practice North Texas Hospital Sean Patrick Dunn, DPM Hess Orthopaedics and Sports Medicine Denton, Texas Faculty Harrisonburg, Pennsylvania The Podiatry Institute William T. DeCarbo, DPM, Attending Surgeon K. Paul Flanigan, DPM, AACFAS DeKalb Medical Center FACFAS Fellowship Trained Foot and Decatur, Georgia Private Practice Ankle Surgeon Staff Physician Portland Foot and Ankle Faculty Northwest Georgia Medical Center Portland, Maine Mountain Valley Foot and Ankle Gainesville, Georgia Reconstruction Fellowship Private Practice Justin J. Fleming, DPM, The Orthopedic Group Oakwood, Georgia FACFAS Pittsburgh, Pennsylvania Faculty Cameron L. Eilts, DPM The Podiatry Institute Alison M. DeWaters, DPM Faculty Decatur, Georgia Private Practice The Podiatry Institute Chief, Foot and Ankle Service Afﬁ liated Foot and Ankle Center Decatur, Georgia Muscle, Bone and Joint Center Howell, New Jersey Private Practice Director, Foot and Ankle Training Sports Medicine Atlantic Orthopedics Aria Health System Lawrence A. DiDomenico, DPM, Portsmouth, New Hampshire Northwest Orthopedic Specialists FACFAS Philadelphia, Pennsylvania Adjunct Professor Lawrence M. Fallat, DPM, Ohio College of Podiatric Medicine FACFAS Lawrence A. Ford, DPM, Visiting Professor Clinical Assistant Professor FACFAS Northeast Ohio Medical University Department of Family Practice Assistant Sub-Chief, Department of Section Chief, Podiatric Medicine and Wayne State School of Medicine Orthopedics and Podiatric Surgery Surgery Director, Podiatric Surgical Residency Kaiser Permanente St. Elizabeth’s Hospital Section Leader Program Director Director, Reconstructive Rearfoot and Podiatry Department of Surgery Kaiser San Francisco Bay Area Foot and Ankle Surgical Fellowship Oakwood Hospital Ankle Residency Ankle and Foot Care Centers Taylor, Michigan Oakland, California Youngstown, Ohio

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Renato J. Giorgini, DPM, Mack Jay Groves IV, DPM, William Harris IV, DPM, FACFAS, FASPS, DABPS, FACFAS AACFAS DABPO Faculty Private Practice Section Chief, Podiatric Surgery The Podiatry Institute Lancaster, South Carolina Director, Podiatric Medical Education Decatur, Georgia Good Samaritan Medical Center St. Tammany Parish Hospital Geoffrey S. Heard, DPM Professor, Division Surgical Sciences Covington, Louisiana Chairman, Podiatry Department New York College of Podiatric Medicine Sequoia Hospital Lindenhurst, New York Charles J. Gudas, DPM, FACFAS Redwood City, California Private Practice Private Practice Tara L. Giorgini, DPM, MD Charleston, South Carolina Belmont, California Faculty The Podiatry Institute George S. Gumann, DPM, John E. Herzenberg, MD, FRCSC Decatur, Georgia FACFAS Director, Pediatric Orthopedics Casa di Cura Quisisana Faculty Director, International Center for Rome, Italy The Podiatry Institute Limb Lengthening Decatur, Georgia Director, Limb Reconstruction Fellowship Robert M. Goecker, DPM, Orthopedic Clinic Program FACFAS Martin Army Hospital Rubin Institute for Advanced Orthopedics Faculty Fort Benning, Georgia Sinai Hospital of Baltimore The Podiatry Institute Clinical Professor, Department of Decatur, Georgia Todd R. Gunzy, DPM, FACFAS Orthopaedics Chief, Podiatric Foot and Ankle Surgery Afﬁ liate Member University of Maryland School of Medicine Sarasota Memorial Hospital The Podiatry Institute Baltimore, Maryland Private Practice Decatur, Georgia Sarasota, Florida Director, Pediatric Foot and Ankle Medical Gina A. Hild, DPM PGY III Sean T. Grambart, DPM, Mission Program Private Practice Kaiser Permanente, Cleveland Clinic FACFAS Mesa, Arizona Foundation Carle Physician Group Cleveland, Ohio Carle Foundation Hospital Todd B. Haddon, DPM, FACFAS Clinical Instructor University of Illinois Linda Ho, DPM School of Medicine Faculty Private Practice Champaign, Illinois The Podiatry Institute Decatur, Georgia Loma Linda, California Private Practice Jaymes D. Granata, MD Mesa, Arizona Claire A. Hollstrom, DPM Private Practice Diplomate, American Board of Lewis Center, Ohio Patrick B. Hall, DPM Podiatric Surgery Faculty Private Practice David J. Granger, DPM, FACFAS The Podiatry Institute Ankle and Foot Center of Georgia Orthopaedic and Spine Specialists Decatur, Georgia LaGrange, Georgia York, Pennsylvania Bone and Joint Clinic of Baton Rouge Baton Rouge, Louisiana Jacob A. Hord, DPM, AACFAS Christa M. Gredlein, DPM, Faculty FACFAS Graham A. Hamilton, DPM, Jewish Hospital Podiatry Residency Private Practice FACFAS Program Baltimore, Maryland Attending Surgeon Louisville, Kentucky Department of Orthopedics and Private Practice Donald R. Green, DPM, FACFAS Podiatric Surgery Shelbyville, Kentucky Faculty Kaiser San Francisco Bay Area Foot and The Podiatry Institute Ankle Residency Program Zeeshan S. Husain, DPM, Decatur, Georgia Antioch, California FACFAS Residency Director Assistant Residency Director Scripps Mercy Kaiser Podiatric Mark A. Hardy, DPM, FACFAS Podiatric Medicine and Surgery Residency Program Staff Residency San Diego, California Ohio Permanente Medical Group, Inc. Detroit Medical Center Clinical Professor Director, Cleveland Clinic Kaiser Detroit, Michigan California School of Podiatric Medicine Permanente Foot and Ankle Residency Oakland, California Cleveland, Ohio Byron L. Hutchinson, DPM, FACFAS Jordan P. Grossman, DPM, Edwin J. Harris, DPM, FACFAS Program Director, Foot and FACFAS Clinical Professor, Orthopaedics and Ankle Institute Afﬁ liate Member Rehabilitation St. Francis Hospital The Podiatry Institute Loyola University Chicago, Stritch School Federal Way, Washington Decatur, Georgia of Medicine Private Practice Private Practice Chicago, Illinois Burien, Washington Akron, Ohio

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Christopher F. Hyer, DPM, MS, Paul J. Kim, DPM, FACFAS George T. Liu, DPM, FACFAS FACFAS Associate Professor, Department of Assistant Professor Fellowship Co-Director Plastic Surgery Department of Orthopaedic Surgery Advanced Foot and Ankle Surgical Division of Wound Healing and Hyperbaric University of Texas Southwestern Fellowship Medicine Medical Center Orthopedic Foot and Ankle Center Georgetown University Hospital Parkland Memorial Hospital Level I Westerville, Ohio Washington, District of Columbia Trauma Center Dallas, Texas Keith L. Jacobson, DPM, Tracy L. Klimaz, DPM, AACFAS FACFAS Private Practice Kieran T. Mahan, DPM, FACFAS Committee Member Virginia Beach, Virginia Faculty Highlands-Presbyterian St. Luke’s The Podiatry Institute Residency Program Constantine S. Kokenes, MD Decatur, Georgia Advanced Orthopedic and Sports Medicine Department of Anesthesiology Associate Dean for Academic Affairs Specialists DeKalb Medical Center Chair and Professor, Department of Denver, Colorado Decatur, Georgia Podiatric Surgery Temple University School of Meagan M. Jennings, DPM, Mark A. Kosinski, DPM, FIDSA Podiatric Medicine FACFAS Professor, Department of Medical Philadelphia, Pennsylvania Department of Orthopedics and Podiatry Sciences Palo Alto Medical Foundation New York College of Podiatric Medicine D. Scot Malay, DPM, MSCE, Chief of Podiatry New York, New York FACFAS El Camino Hospital Instructor, Department of Surgery Faculty Mountain View, California New York Medical College The Podiatry Institute Valhallah, New York Decatur, Georgia A. Louis Jimenez, DPM, FACFAS Director of Podiatric Research and Faculty Bradley M. Lamm, DPM, FACFAS Staff Surgeon The Podiatry Institute Head of Foot and Ankle Surgery Penn Presbyterian Medical Center Decatur, Georgia International Center for Private Practice Program Director, Atlanta VAMC Podiatric Limb Lengthening Ankle and Foot Medical Centers of the Residency Program Director, Foot and Ankle Deformity Delaware Valley Past President, American College Foot and Correction Fellowship Philadelphia, Pennsylvania Ankle Surgeons Rubin Institute for Advanced Private Practice Orthopedics Dennis E. Martin, DPM, FACFAS Gwinnett Foot, Ankle Leg Centers Sinai Hospital Faculty Snellville, Georgia Baltimore, Maryland The Podiatry Institute Decatur, Georgia Shine John, DPM, AACFAS Adam S. Landsman, DPM, PhD, Private Practice Foot Specialists FACFAS North Charleston, South Carolina Cedar Park, Texas Assistant Professor of Surgery Harvard Medical School Suhail B. Masadeh, DPM, FACFAS Warren S. Joseph, DPM, FIDSA Chief, Division of Podiatric Surgery Faculty Consultant Cambridge Health Alliance American Health Network Fellowship Lower Extremity Infectious Diseases Cambridge, Massachusetts Advanced Reconstructive Foot and Roxborough Memorial Hospital Ankle Surgery Philadelphia, Pennsylvania Stephan J. LaPointe, DPM, PhD, Private Practice FACFAS Muncie, Indiana Molly A. Judge, DPM, FACFAS Faculty Director, Publications and Research The Podiatry Institute Michael P. Maskill, DPM Podiatric Residency Program Decatur, Georgia Orthopaedic Associates of Kalamazoo Cleveland Clinic Foundation–Kaiser Private Practice Department of Foot and Ankle Surgery Permanente Foundation Rome, Georgia Kalamazoo, Michigan Cleveland, Ohio Adjunct Faculty Gretchen A. Lawrence, DPM, E. Dalton McGlamry, DPM, DSc Ohio University and Colleges of AACFAS (Hon), DHL Podiatric Medicine Private Practice Founding Member Faculty Waynesville, North Carolina The Podiatry Institute Graduate Medical Education Decatur, Georgia Mercy Health Partners Michael S. Lee, DPM, FACFAS Private Practice Adjunct Clinical Professor Michael C. McGlamry, DPM, Toledo, Ohio Des Moines University FACFAS Past President Faculty Carl A. Kihm, DPM American College of Foot and The Podiatry Institute Faculty Ankle Surgeons Decatur, Georgia The Podiatry Institute Private Practice Private Practice Decatur, Georgia Capital Orthopaedics and Sports Cumming, Georgia Private Practice Medicine, PC Douglasville, Georgia Clive, Iowa

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Robert W. Mendicino, DPM, William G. Montross, DPM, Lawrence S. Osher, DPM FACFAS FACFAS Professor, Department of Foot and Ankle Surgery Attending Physician Podiatric Medicine Pinnacle Orthopedic Associates Denver Veterans Administration Hospital Ohio College of Podiatric Medicine Salisbury, North Carolina Podiatric Residency Independence, Ohio Denver, Colorado Allison J.A. Menke, DPM, Assistant Clinical Professor Kittra T. Owens, DPM AACFAS Rocky Vista Osteopathic College Division Ofﬁ cer, Department of Parker, Colorado Orthopedics Faculty Naval Hospital The Podiatry Institute Camp Lejeune, North Carolina Decatur, Georgia Jared L. Moon, DPM Attending Surgeon Faculty DeKalb Medical Center The Podiatry Institute Charles F. Peebles, DPM, Decatur, Georgia Decatur, Georgia FACFAS Private Practice Faculty Thomas J. Merrill, DPM, Chicago, Illinois The Podiatry Institute FACFAS Decatur, Georgia Faculty James H. Morgan Jr, DPM, Private Practice The Podiatry Institute FACFAS, FAAPSM Atlanta, Georgia Decatur, Georgia Faculty Professor of Surgery The Podiatry Institute Jorge G. Penagos Vasquez, MD Barry University School of Decatur, Georgia Chief, Department of Orthopaedic Surgery Podiatric Medicine Private Practice and Foot and Ankle Miami Shores, Florida Mobile, Alabama Pediatric Foundation of Guatemala City Residency Director Guatemala City, Guatemala Mercy Hospital Robb A. Mothershed, DPM, Miami, Florida FACFAS Keith D. Pfeifer, DPM Faculty Assistant Residency Director Amanda Meszaros, DPM, The Podiatry Institute Eisenhower Army Medical Center FACFAS Decatur, Georgia Fort Gordon, Georgia Co-Chair, Department of Surgery AO Alumnus Mercy Allen Hospital Department of Orthopedics Jane Pontious, DPM, FACFAS Private Practice University of Washington Faculty Oberlin, Ohio Seattle, Washington The Podiatry Institute Private Practice Decatur, Georgia Justin T. Meyer, DPM Winston-Salem, North Carolina Chair, Department of Surgery Faculty Assistant Dean of Clinical Education The Podiatry Institute Travis A. Motley, DPM, MS, Temple University School of Decatur, Georgia FACFAS Podiatric Medicine Private Practice Associate Professor Philadelphia, Pennsylvania Santa Barbara, California Department of Orthopaedic Surgery Bone and Joint Institute Donald R. Powell, DPM Andrew J. Meyr, DPM, AACFAS University of North Texas Health Faculty Assistant Professor, Department of Science Center The Podiatry Institute Podiatric Surgery Fort Worth, Texas Attending Surgeon Temple University School of DeKalb Medical Center Podiatric Medicine Aprajita Nakra, DPM, FACFAS Decatur, Georgia Philadelphia, Pennsylvania Faculty The Podiatry Institute Decatur, Georgia Linnie V. Rabjohn, DPM, J. Michael Miller, DPM, FACFAS FACFAS Director of Fellowship Training Private Practice Private Practice Foot and Ankle Reconstructive Phoenix and Gilbert, Arizona Arlington/Mansﬁ eld Foot and Surgical Service Ankle Centers American Health Network Alan Ng, DPM, FACFAS Arlington, Texas Indianapolis, Indiana Advanced Orthopedic and Sports Medicine Specialists Stephen J. Miller, DPM Residency Committee Highlands/ Johanna-Marie Richey, DPM, BBS Faculty Presbyterian St. Luke’s Medical Center Chief Resident The Podiatry Institute Denver, Colorado Kaiser San Francisco Bay Area Foot and Decatur, Georgia Ankle Anacortes, Washington Lawrence M. Oloff, DPM San Francisco, California Diplomate, American Board of Hilaree B. Milliron, DPM Podiatric Surgery Private Practice Sports Orthopedic and Rehabilitation Jacksonville Beach, Florida (SOAR) Medical Group Redwood City, California

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Thomas S. Roukis, DPM, PhD, Sarah A. Spizzirri, DPM, AACFAS Marija Ugrinich, DPM, AACFAS FACFAS Private Practice Staff Surgeon Department of Orthopaedics Christie Clinic Penn Presbyterian Medical Center Podiatry and Sports Medicine Champaign, Illinois Private Practice Gundersen Lutheran Medical Center Ankle and Foot Medical Centers of the La Crosse, Wisconsin John J. Stapleton, DPM, FACFAS Delaware Valley Foot and Ankle Surgery Philadelphia, Pennsylvania John A. Ruch, DPM, FACFAS VSAS Orthopaedics Chief of Podiatric Surgery John V. Vanore, DPM, FACFAS Director of Medical Education Faculty The Podiatry Institute Leigh Valley Hospital Allentown, Pennsylvania The Podiatry Institute Attending Surgeon Decatur, Georgia DeKalb Medical Center Clinical Assistant Professor of Surgery Penn State College of Medicine Private Practice Decatur, Georgia Gadsden, Alabama Private Practice Hershey, Pennsylvania Village Podiatry Centers Harold W. Vogler, DPM, FACFAS Tucker, Georgia Jerome K. Steck, DPM, FACFAS Private Practice Past Chairman, Department of Surgery Southern Arizona Orthopedics Pennsylvania College of Shannon M. Rush, DPM, FACFAS Tucson, Arizona Podiatric Medicine Director, Silicon Valley Foot and Philadelphia, Pennsylvania Past Chairman, Section of Foot and Ankle Fellowship Dawn Y. Stein, DPM, CWS Palo Alto Medical Foundation Ankle Surgery Department of Podiatry Mountain View, California Sarasota Memorial Hospital Grove City Medical Center Partner and Fellowship Director Grove City, Pennsylvania Sarasota Orthopedic Associates Jay D. Ryan, DPM, AACFAS Sarasota, Florida Faculty John S. Steinberg, DPM, The Podiatry Institute FACFAS Carl R. Wagreich, DPM Decatur, Georgia Associate Professor Associate Clinical Professor Staff Physician Department of Plastic Surgery University of Southern California Inova Fairfax Hospital Georgetown University School Los Angeles, California Fairfax, Virginia of Medicine Residency Director Program Director HealthSouth Surgery Center of South Bay/ John M. Schuberth, DPM MedStar Washington Hospital Center Baja Project Surgical Residency Program Faculty Podiatric Residency Torrance, California The Podiatry Institute Co-Director, Center for Wound Healing Co-Director, Baja Project for Decatur, Georgia MedStar Georgetown University Hospital Crippled Children Chief, Foot and Ankle Surgery Washington, District of Columbia Mexicali, Mexico Department of Orthopedic Surgery Kaiser Foundation Hospital John J. Stienstra, DPM, George F. Wallace, DPM, San Francisco, California FACFAS FACFAS Department of Orthopedics Director, Podiatry Service Jaclyn M. Schwartz, DPM The Permanente Medical Group Medical Director, Ambulatory Care Services Senior Resident Union City, California University Hospital DeKalb Medical Center University of Medicine and Dentistry of Decatur, Georgia Tod R. Storm, DPM, FACFAS New Jersey Active Staff Newark, New Jersey Thomas F. Smith, DPM, FACFAS Bozeman Deaconess Hospital Faculty Bozeman, Montana Mari Wargo-Dorsey, DPM, The Podiatry Institute AACFAS Decatur, Georgia Robert P. Taylor, DPM, FACFAS Private Practice Chairman, Podiatry Section Faculty The Ankle and Foot Care Centers University Hospital The Podiatry Institute Boardman, Ohio Podiatry Staff Decatur, Georgia Charlie Norwood VAMC Adjunct Faculty R. David Warren, DPM, Augusta, Georgia Department of Medicine FACFAS Consultant Baylor Medical Center Private Practice Eisenhower Army Medical Center Garland, Texas Arlington, Texas Fort Gordon, Georgia Private Practice Frisco, Texas Steven A. Weiskopf, DPM, Joe T. Southerland, DPM, FACFAS FACFAS Faculty James L. Thomas, DPM, Faculty The Podiatry Institute FACFAS The Podiatry Institute Decatur, Georgia Chief, Division of Foot and Ankle Decatur, Georgia Private Practice Department of Orthopaedic Surgery Private Practice Arlington/Mansﬁ eld Foot and University of Florida Woodstock, Georgia Ankle Centers Jacksonville, Florida Arlington, Texas

Southerland_FM.indd xv 7/31/2012 1:03:35 PM xvi Contributing Authors

Mitzi L. Williams, DPM, FACFAS Jon M. Wilson Jr, DPM, AACFAS Thomas M. Zgonis, DPM, Young Afﬁ liate Member Department of Surgery FACFAS The Podiatry Institute St. Tammany Parish Hospital Associate Professor, Department of Decatur, Georgia Lakeview Regional Medical Center Orthopaedics Attending Surgeon Covington, Louisiana Division Chief, Externship San Francisco Bay Area Foot and Ankle Fellowship Program Director Residency Program Robyn Winner, DPM University of Texas Health Science Center Department of Orthopedics and Private Practice San Antonio, Texas Podiatric Surgery Seattle, Washington Kaiser Permanente Hospital Richard J. Zirm, DPM Oakland, California Daniel J. Yarmel, DPM, AACFAS, Faculty AAPWCA The Podiatry Institute Jason J. Willis, DPM, AACFAS Private Practice and Attending Faculty Decatur, Georgia Attending Podiatrist Pinnacle Health Hospitals Department of Surgery Foot Centers of Texas Harrisburg, Pennsylvania Southwest General Health Center Methodist Sugar Land Hospital Private Practice Sugar Land, Texas Cleveland, Ohio

Southerland_FM.indd xvi 7/31/2012 1:03:35 PM Southerland_FM.indd xvii 7/31/2012 1:03:35 PM Southerland_FM.indd xviii 7/31/2012 1:03:36 PM Southerland_FM.indd xix 7/31/2012 1:03:36 PM CHAPTER John A. Ruch Lopa Dalmia 58 Patrick B. Hall Triple Arthrodesis

The triple arthrodesis performed today is a variation of the is diffi cult to position the foot adequately to assess the true procedure described by Ryerson in 1923 (1). Modifi cations amount of ankle dorsifl exion until the joints have been resected have evolved out of the need to meet new challenges as the at the time of surgery. In contrast, ankle joint dorsifl exion in triple arthrodesis has been applied to a greater variety of disor- patients with a pes cavus deformity may fi rst appear inadequate ders (2–12). The basic aim of a triple arthrodesis is to improve because of the increase in the osseous height from the maxi- foot function by providing stability, correction of deformity, mally supinated position of the midtarsal joint and STJ. Upon and elimination of pain. Providing the patient with a stable, restoring a more plantigrade osseous alignment after fusion, pain free platform for ambulation through triple arthrodesis one may note a suitable increase in the dorsifl exory motion at offers gratifying and predictable results for a variety of foot the ankle. deformities (13–23). Perhaps the most critical aspect of triple arthrodesis is the ultimate position of the foot after fusion. Poor or inappropriate positioning of the foot may be one of the primary reasons for INDICATIONS residual pain and the creation of adjacent arthritis postoperatively. The heel should be aligned to rest in a neutral to slightly In the broadest sense, the triple arthrodesis is used to achieve everted position. The greatest success in triple arthrodesis has four major goals: correction of deformity, relief of pain, stabi- been achieved with the midtarsal joint positioned in slight val- lization, and improved function. The dominant deformity in gus when fused, that is, with the medial column slightly plan- the early twentieth century was fl accid paralysis secondary to tarfl exed relative to the lateral column. This position increases poliomyelitis. Today, various conditions are amenable to repair the stability of the medial column and fi rst ray, permitting with triple arthrodesis. Table 58.1 refl ects the wide range of enhanced fi rst metatarsophalangeal joint motion. The valgus diagnoses in which this surgery is performed. Many of these positioning may also be more easily accommodated with an disease processes refl ect similar deformities; each of the major orthotic device postoperatively. If the medial column is dorsi- deformities can be categorized into valgus, varus, or miscellane- fl exed relative to the lateral column, the patient is left with a ous conditions (Table 58.2). fi xed forefoot varus deformity for which no suitable compensa- tion exists. PREOPERATIVE CONSIDERATIONS It is important to plan the alignment of the forefoot to the rearfoot and the rearfoot to the leg (Fig. 58.1). This is especially critical in determining the fi nal position of fusion. The foot Certain considerations should be made before triple arthro- normally exhibits 10 to 15 degrees of abduction from the line of desis is performed. These include patient expectations, the progression in gait. In arthrodesis of the rearfoot, the surgeon desired goal of the fusion and its functional effect, timing of the must know the position of the knee during gait as well as dur- surgical intervention, biomechanical and positional considera- ing the surgical procedure. If the knee functions when medially tions of the subtalar joint (STJ) and midtarsal joint, the position rotated at 15 degrees, then it would be desirable to abduct the and alignment of the ankle and leg, bone quality, soft tissue foot on the leg 30 degrees, thus resulting in a 15-degree abduc- quality, the patient’s age, and the anticipated recovery time. tion from the line of progression. It is not advisable to abduct a Candidates for triple arthrodesis usually possess conditions foot if the patient already possesses 15 to 30 degrees of lateral that have proven resistant to conservative therapy, or they have position of the knee in gait. In the latter instance, the foot may a condition that cannot be expected to respond to conserva- be aligned directly with the knee. tive measures and one in which the surgeon can expect an ade- These preoperative assessments are aided by a series of quate result with fusion. The elimination of STJ and midtarsal weight-bearing radiographs (Fig. 58.2) including dorsoplan- joint motion may restrict the ability of the patient to adapt to tar, medial oblique, lateral, and calcaneal axial views. Weight- uneven surfaces and terrain; however, in candidates for triple bearing fi lms allow a more representative view of osseous arthrodesis, this motion is often either painful or absent preop- alignment. The degree of deformity should be evaluated in eratively. Additionally, the existing deformity often prevents the each of the cardinal planes prior to proceeding with surgical motion from serving any benefi t for the patient, due to either reconstruction. painful arthritis or uncontrollable instability. Evaluation of ankle joint range of motion is a critical part of the preoperative assessment. This may reveal either an arthritic TECHNIQUE limitation or a soft tissue equinus contracture, altering the surgical plan. Careful examination needs to be performed in a MEDIAL INCISION/DISSECTION patient with a severely collapsed pes valgus deformity because signifi cant amounts of dorsifl exion may occur at the midtar- Landmarks for the medial approach to triple arthrodesis sal joint level. In patients with rigid pes valgus conditions, it include the medial gutter of the ankle joint proximally and 829

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TABLE 58.1 Conditions That May Benefi t from TABLE 58.2 Indications for Triple Arthrodesis Triple Arthrodesis Valgus foot deformities Idiopathic collapsing pes planovalgus deformity Collapsing pes planovalgus deformity Peroneal spastic fl atfoot Tibial posterior tendon dysfunction Tarsal coalition Tarsal coalition Congenital vertical talus Arthritic conditions Chronic pain Rheumatoid arthritis Rheumatoid arthritis Degenerative arthritis Degenerative arthritis Posttraumatic arthritis Posttraumatic arthritis Chronic pain Charcot arthropathy Varus foot deformities Tibial posterior tendon dysfunction Cavus and cavovarus Idiopathic cavus and cavovarus deformities Talipes equinovarus Residual or uncorrected clubfoot Miscellaneous conditions Poliomyelitis Joint instability Spina bifi da Neuromuscular disease Friedreich ataxia Hereditary familial sensorimotor neuropathies Charcot-Marie-Tooth disease Paralytic deformities Muscular dystrophy Cerebral palsy Cerebral palsy Charcot arthropathy Myelodysplasia Other diseases affecting the spinal cord and brain Arthrogryposis Joint instability

the inferior aspect of the navicular cuneiform joint (Fig. 58.3). This oblique orientation provides full exposure of the talonavicular joint and allows for screw fi xation of the STJ and the talonavicular joint. A dorsal to plantar fi xation of the STJ utilizes insertion of the large cancellous screw at the dorsal medial aspect of the talar neck. Fixation of the talonavicular joint with a large cancellous screw is directed from the distal inferior aspect of the navicular up into the head and neck of the talus. Medial skin incision for exposure of the talonavicular joint and insertion of the TN screw and the talocalcaneal screw extends from the medial gutter of the ankle to inferior aspect of the navicular cuneiform joint (Fig. 58.4A). The greater saphen- ous vein will usually be encountered during dissection through the subcutaneous layers. Inferior tributaries may be transected and ligated and the main portion of the vein refl ected superiorly (Fig. 58.4B). The primary incision for exposure of the talonavicular joint is made through the deep fascia and capsule along

Figure 58.1 Relationship of the knee position to the foot. A: Rec- tus knee and foot. B: Rectus knee with the foot abducted 30 degrees. C: Internal knee position with the foot adducted 25 degrees.

Figure 58.3 Landmarks for the medial approach to triple arthrodesis include the medial gutter of the ankle joint proximally and the Figure 58.2 Preoperative radiograph. inferior aspect of the navicular cuneiform joint.

Southerland_Chap58.indd 830 6/20/2012 2:59:51 PM Chapter 58 • Triple Arthrodesis 831

Figure 58.4 A: Medial skin incision. B: Dissection through the subcutaneous layers. C: Primary incision for exposure of the talonavicular joint.

the dorsal medial aspect of the joint. The incision extends from incision allows for deliverance of the head of the talus without the medial gutter of the ankle joint to the navicular cuneiform refl ecting capsular tissues of the medial aspect of navicular. joint (Fig. 58.4C). A secondary incision is made vertically along the proximal The capsular incision for the talonavicular joint is a medial edge of the navicular but does not usually transect the T incision (Fig. 58.5A and B). The dorsal medial longitudi- tibialis posterior tendon (Fig. 58.5C and D). This modifi cation nal incision allows for refl ection of capsular tissues for the in the talonavicular incision leaves capsule and periosteal tis- dorsal aspect of the talonavicular joint. The vertical medical sues intact over the medial aspect of the navicular. The capsule

A B

Figure 58.5 A,B: Capsular incision for the talonavicular joint. (Continues on next page)

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Figure 58.5 (Continued) C,D: Secondary incision is made vertically along the proximal medial edge of the navicular but does not usually transect the tibialis posterior tendon. E: Reﬂ ection of the capsule from the dorsal surface of the talonavicular joint.

is refl ected from the dorsal surface of the talonavicular joint and penetration into talar head (Fig. 58.6C). This technique is and will routinely release the dorsal talonavicular ligament extremely helpful because of the convex contour of the talar head. (Fig. 58.5E). This modifi cation in the arthrotomy of the talon- The depth of the osteotome is directed beneath the subchondral avicular joint provides full exposure and minimizes soft tissue plate in a mosaic pattern designed to resect the articular surface or periosteal refl ection. and preserve the contour of the head of the talus (Fig. 58.6D). The small lamina spreader is repositioned for resection of the articular surface of the navicular (Fig. 58.7A). Curettage TALONAVICULAR JOINT RESECTION technique is used to remove the articular cartilage on the navic- Joint resection starts with contour resection of the talar head ular (Fig. 58.6B). (Fig. 58.6A). The contour joint resection technique of the talar Care is taken to maintain the dorsal rim of the bone to head preserves the shape of the joint and minimizes bone resec- assure bone-to-bone contact of the convex talar head and the tion. Preservation of the joint contour also allows for manual concave navicular surface (Fig. 58.7C). A rotary oval burr is repositioning of the midtarsal joints by a normal rotation of the used to penetrate the subchondral plate (Fig. 58.7D and E). medial column. Contour resection of the articular cartilage and Distraction of the talonavicular joint with a lamina spreader subchondral plate of the talar head is performed with the use of a demonstrates the resection of the articular surfaces of the head small osteotome (no. 10) and mallet (Fig. 58.6B). The osteotome of the talus and the concave surface of the navicular exposing is advanced only several millimeters to avoid excessive depth raw cancellous bone (Fig. 58.7F).

Southerland_Chap58.indd 832 6/20/2012 2:59:53 PM Chapter 58 • Triple Arthrodesis 833

Figure 58.6 A: Contour resection of the talar head. B: Contour resection of the articular cartilage and subchondral plate of the talar head. C,D: Osteotome advancement.

LATERAL INCISION/DISSECTION calcaneal cuboid joint (CCJ). The incision is usually between the course of the sural nerve and the intermediate dorsal cuta- Landmarks for the lateral approach for triple arthrodesis neous nerve. Controlled depth incision technique is used to include the distal tip of the ﬁ bular malleolus and the junction separate the skin and to avoid laceration of the underlying of the fourth and ﬁ fth metatarsal bases (Fig. 58.8A). A relatively veins (Fig. 58.8B). Dissection through the subcutaneous tis- straight line incision between these two points crosses the infe- sues exposes the deep fascia over the extensor digitorum brevis rior edge of the sinus tarsi and the dorsal lateral aspect of the

Figure 58.7 A: Repositioning of the small lamina spreader. B: Removal of the articular cartilage on the navicular. (Continues on next page)

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Figure 58.7 (Continued) C: The dorsal rim of bone is maintained. D,E: A rotary oval burr is used to penetrate the subchondral plate. F: Head of the talus and concave surface of the navicular, exposing raw cancellous bone.

(EDB) muscle belly (Fig. 58.8C). Superfi cial veins that crossed muscle belly, using blunt sponge technique (Fig. 58.8E). The the incision may be ligated or cauterized. A communicating primary purpose of this separation between the layers is to branch of the sural nerve to the intermediate dorsal cutaneous facilitate wound closure. The tendon of the peroneus tertius is nerve may be encountered. If the nerve can be safely retracted, encountered overlying the EDB muscle belly. it is preserved, but more often it is sacrifi ced (Fig. 58.8D). The The anatomic pathway to the STJ and CCJ lies between superfi cial fascia or the subcutaneous layer is easily separated the inferior edge of the EDB muscle belly and the superior from the deep fascia, especially over the extensor digitorum aspect of the peroneal tendons (Fig. 58.9A). Refl ection of

Figure 58.8 A: Landmarks for the lateral approach for triple arthrodesis include the distal tip of the ﬁ bular malleolus and the junction of the fourth and ﬁ fth metatarsal bases. B: Controlled depth incision technique to separate the skin and to avoid laceration of the underlying veins.

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Figure 58.8 (Continued) C: Exposure of the deep fascia over the EDB muscle belly. D: Communicating branch of the sural nerve to the intermediate dorsal cutaneous nerve. E: Separation of the superﬁ cial fascia or the subcutaneous layer from the deep fascia, especially over the extensor digitorum muscle belly, using blunt sponge technique.

the subcutaneous tissues reveals the key dissection landmarks of the CCJ (Fig. 58.9E). A venous plexus is consistently identi- for deep fascial incision: the junction of the inferior edge of ﬁ ed beneath the muscle belly overlying the cuboid. This venous the EDB muscle belly and the course of the peroneal tendons plexus should be isolated and ligated (Fig. 58.9F and G). (Fig. 58.9B and C). The deep fascia incision is placed at the The EDB muscle origin from the anterolateral aspect of inferior edge of EDB muscle just superior to the peroneal the sinus tarsi is visualized (Fig. 58.10A). The muscle belly is retinaculum and the sheath extending into the sinus tarsi retracted for visualization of the dorsal lateral aspect of the (Fig. 58.9D). The edge of the EDB muscle belly is easily CCJ. The peroneal tendons should be totally ensheathed. reﬂ ected from the capsular tissue over the dorsal lateral aspect The lateral process of the talus is the key structure for

Figure 58.9 A: Anatomic pathway to the STJ and CCJ. B,C: The key dissection landmarks for deep fascial incision. (Continues on next page)

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Figure 58.9 (Continued) D: Placement of the deep fascia incision. E: The edge of the EDB muscle belly is easily reﬂ ected from the capsular tissue over the dorsal lateral aspect of the CCJ. F,G: The venous plexus is isolated and ligated.

orientation of the periosteal incision and identifi cation of the STJ entrance to the sinus tarsi (Fig. 58.10E). The incision is then (Fig. 58.10B). An inverted-L lateral incision is planned for extended distally along the dorsal lateral edge of the calca- exposure of STJ and CC joints. The capsular incision for expo- neus, across the CCJ, and out to the metatarsal cuneiform sure of the STJ and CCJ refl ects the EDB muscle belly subperi- articulation. osteally from the dorsal aspect of the calcaneus and the cuboid The EDB muscle belly is then refl ected from the dorsal (Fig. 58.10C). A vertical incision is made at the anterior edge surface of the cuboid and the dorsal aspect of the calcaneus of the lateral process of the talus (Fig. 58.10D). This incision (Fig. 58.11A). This dissection of the sinus tarsi communicates encounters the dorsal lateral edge of the calcaneus and the with the elevation of the dorsal tissue over the calcaneocuboid

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Figure 58.10 A: The EDB muscle origin from the anterolateral aspect of the sinus tarsi. B: The lateral process of the talus is the key structure for orientation of the periosteal incision and identiﬁ cation of the STJ. C: Capsular incision for exposure of the STJ and CCJ. D,E:Vertical incision made at the anterior edge of the lateral process of the talus and extended distally along the dorsal lateral edge of the calcaneus, across the CCJ and out to the metatarsal cuneiform articulation.

joint as an intact tissue fl ap. The subperiosteal or submuscu- CALCANEAL CUBOID JOINT RESECTION lar dissection is carried across the dorsal surface of the calca- Correction of the transverse plane deformity, abduction, or neal cuboid region to the lateral aspect of the talonavicular adduction of the forefoot is exclusively at the midtarsal joints. joint complex (Fig. 58.11B and C). A fi brofatty plug that In the adducted forefoot, a laterally based wedge is performed fi lls the sinus tarsi is circumscribed and then dissected away in the CCJ to abduct the forefoot. Saw resection is the preferred from the lateral aspect of the head and neck of the talus (Fig. technique of resection for the CCJ (Fig. 58.12). 58.11D and E).

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Figure 58.11 A: EDB muscle belly refl ected from the dorsal surface of the cuboid and the dorsal aspect of the calcaneus. B,C: The EDB muscle belly has been elevated from the dorsal aspect of the calcaneus and cuboid, exposing the CCJ and the anterior margin of the posterior facet of the STJ. D: A fi brofatty plug that fi lls the sinus tarsi is circumscribed and then dissected away from the lateral aspect of the head and neck of the talus. E: A close-up view following resection of the fi brofatty plug of the sinus tarsi demonstrates the middle facet of the STJ.

Joint resection begins with the articular surface of the cal- subchondral plate of the cuboid are resected with clear visu- caneus. A 1- to 2-mm wedge of the articular surface and the alization of the resected calcaneal surface (Fig. 58.13D and E). subchondral plate is resected (Fig. 58.13A). Correction for transverse plane deformity can be achieved with resecting more SUBTALAR JOINT RESECTION for this surface (Fig. 58.13B). A ﬁ sh scale pattern is created in the subchondral bone surface of the calcaneus for good bone- Contour resection of the articular surfaces of the STJ is to-bone contact (Fig. 58.13C). The articular cartilage and the performed with the use of a small osteotome and mallet

Southerland_Chap58.indd 838 6/20/2012 3:00:11 PM Chapter 58 • Triple Arthrodesis 839

(Fig. 58.14A and B). The osteotome is directed just beneath the subchondral bone plate and penetrates approximately 5 to 8 mm into the substance of the calcaneus. This controlled penetration is used to maintain the contour of the posterior facet and avoid excessive bone resection (Fig. 58.14C). Sequential resection of the remaining portions of the facet is performed again in incremental segments (Fig. 58.14D), allowing the surgeon to sculpt or maintain the contour of the original joint facet with a mosaic pattern of joint resection. A similar technique is used for resection of the articular cartilage and subchondral bone plate of the talar component of the posterior facet (Fig. 58.14E and F). Resection of the articular cartilage and the subchondral bone plate from the concave talar portion of the posterior facet is performed by sequential small sections to follow the contour of the facet and avoid fragmentation of the large medial shelf of the talus (Fig. 58.15A). Again, the oste- Figure 58.12 Laterally based wedge in the CCJ to abduct the otome is advanced only several millimeters to avoid excessive adducted forefoot. depth and penetration into the posterior aspect of the talus

Figure 58.13 A: A 1- to 2-mm wedge of the articular surface and the subchondral plate is resected. B: Transverse plane deformity is corrected by resecting more of this surface. C: Fish scale pattern created in the subchondral bone surface of the calcaneus. (Continues on next page)

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Figure 58.13 (Continued) D,E: Resection of the articular cartilage and the subchondral plate of the cuboid.

Figure 58.14 A: An anterior lateral view of the STJ demonstrates the articular surface of the calcaneal portion of the posterior facet and middle facet overlying the sustentaculum tali. The joint is distracted with the use of a small lamina spreader. B: Contour resection of the articular surfaces of the STJ. C: The osteotome is directed just beneath the subchondral bone plate and penetrates approximately 5 to 8 mm into the substance of the calcaneus.

Southerland_Chap58.indd 840 6/20/2012 3:00:16 PM Figure 58.14 (Continued) D,E: Sequential resection of the remaining portions of the facet and of the articular cartilage and subchondral bone plate of the talar component of the posterior facet. F: The osteotome is placed at the anterior lateral aspect of the joint and directed just beneath the subchondral plate following the slope of the anterior portion of the facet.

(Fig. 58.15B). This technique is extremely helpful because allows for manual repositioning of the STJ and midtarsal of the concave contour of the talar portion of the posterior joint by a normal rotation of the STJ complex. The calcaneal facet. The contour joint resection technique of the posterior portion of the middle facet is identiﬁ ed and is resected in a facet of the STJ preserves the shape of the joint and mini- similar subchondral plate resection technique (Fig. 58.15D). mizes bone resection and loss of height of the rearfoot com- The talar surface of the middle facet is also resected with an plex (Fig. 58.15C). Preservation of the joint contour also osteotome (Fig. 58.15E and F).

Figure 58.15 A: Resection of the articular cartilage and the subchondral bone plate from the concave talar portion of the posterior facet. (Continues on next page)

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Figure 58.15 (Continued) B: The osteotome is advanced only several millimeters to avoid excessive depth and penetration into the posterior aspect of the talus. C: Strategic segmental resection of the articular cartilage and subchondral plate of the talar portion of the posterior facet maintain the contour of the joint. D: The calcaneal portion of the middle facet is resected. E: The talar surface of the middle facet is resected with an osteotome. F: Completed contour resection of the STJ and talonavicular joint.

ALIGNMENT/TEMPORARY FIXATION and alignment of the foot to the leg. The optimal position for the rearfoot complex is identifi ed and temporarily fi xated with Contour resection of the STJ and talonavicular joint allows for the insertion of Steinmann pins (Fig. 58.16A). Alignment of the manual repositioning or realignment of the rearfoot complex. talonavicular joint is performed initially and temporarily fi x- This joint resection technique allows the surgeon to position the ated with a Steinmann pin (Fig. 58.16B). With contour resec- foot into a stable plantar grade alignment by manipulating the tion of the STJ and midtarsal joint, optimal positioning of the rearfoot joints through a relatively normal joint range of motion talonavicular joint will usually create the desired alignment

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Figure 58.16 Steinmann pins are used for temporary ﬁ xation of the rearfoot complex (A), the talonavicular joint (B), and the STJ and midtarsal joint (C).

and apposition of the STJ and CCJ. Temporary fi xation of the navicular and directed proximally up into the neck of the STJ and midtarsal joint has been performed with insertion of talus (Fig. 58.17D and E). The CCJ is fi xated with a large can- Steinmann pins (Fig. 58.16C). The pins may be used for rela- cellous screw (16-mm thread pattern). The screw is inserted tive guidance for insertion of the permanent fi xation devices. If from the dorsal lateral aspect of the distal cuboid and directed traditional noncannulated cancellous screws are utilized, posi- proximally across the CCJ and into the midportion of the tioning of the temporary fi xation pins should be offset from the body of the calcaneus (Fig. 58.17F–H). optimal point of penetration intended for the permanent fi xa- If screw purchase is not completely secure and adequate, tion devices. If cannulated screw fi xation is intended, the guide- apposition and alignment of the joint may be forced with the wires are placed in the optimum position for the fi xation device. insertion of staple fi xation (Fig. 58.18).

PERMANENT FIXATION CLOSURE Permanent fi xation of the STJ is usually performed initially. A 3.2- Closed-suction drains are routinely employed to extravasate soft mm drill is inserted in the dorsal medial aspect of the neck of tissue and cancellous bone bleeding after closure of the surgi- the talus and directed toward the posterior, inferior lateral corner cal wounds (Fig. 58.19A). This technique helps avoid formation of the calcaneus (Fig. 58.17A and B). A large 6.5-mm cancellous of signifi cant hematoma. Layered wound closure is employed screw with a 32-mm thread pattern is inserted for compression to restore normal anatomic tissue layers and minimizes dead fi xation of the STJ (Fig. 58.17C). Intraoperative x-rays should be space that may lead to hematoma and other wound compli- used to confi rm the position and alignment of the fi xation devices. cations (Fig. 58.19B). The skin incisions are usually sutured Fixation of the talonavicular joint is performed by the with an intradermal technique utilizing absorbable sutures insertion of a large cancellous screw (16-mm thread pat- (Fig. 58.19C). The incision lines are reinforced with Steri-Strips. tern), which is inserted from the distal inferior aspect of the The surgical area is usually infi ltrated with a long-acting local

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anesthetic to provide analgesia following the surgical procedure. is applied following wound closure to control edema. Several A well-padded Jones compression dressing and short leg cast are days later, the cast is removed and the wound is assessed and the usually employed for the postoperative dressing (Fig. 58.19). extent of the edema is evaluated. A below-the-knee cast is reap- plied for the remainder of the postoperative phase.

POSTOPERATIVE CONSIDERATIONS PHASE II: WOUND HEALING (DAY 5 TO 4 WEEKS) Postoperative management of triple management can be This is a period of wound healing and resolution of the inﬂ am- viewed as a sequence of phases from the day of surgery up to matory response. The patient is to remain non-weight-bearing 1 year after surgery. throughout this phase. If signiﬁ cant edema is present, bivalving the cast is an option. PHASE I: INITIAL MANAGEMENT (DAYS 0 TO 5) PHASE III: CONSOLIDATION (WEEKS 4 TO 8) Initial management begins with placement of closed-suction drainage system medially and laterally to evacuate hemorrhagic Radiographs are obtained at 3 to 4 weeks postoperatively drainage after closure of the incision. A Jones compression cast to assess the progress of osseous healing (Fig. 58.20). The

Figure 58.17 A: Drill insertion for permanent ﬁ xation of the STJ. B,C: Orienta- tion of the talocalcaneal screw is from the dorsomedial aspect of the neck of the talus perpendicular across the posterior facet of the STJ to the posterior lateral corner of the calcaneus. D,E: Orientation of the talonavicular screw is from the medial, distal inferior aspect of the navicular, up the neck of the talus and into the midsubstance of the dome of the talus.

Southerland_Chap58.indd 844 6/20/2012 3:00:28 PM F

Figure 58.17 (Continued) F,G: Orientation of the calcaneal–cuboid screw is from the distal dorsal lateral aspect of the cuboid, across the CCJ toward the medial wall of the calcaneus below the sustentaculum tali. H: A composite view of ﬁ xation of the talonavicular joint, talocalcaneal joint, and CCJ for triple H arthrodesis.

Figure 58.18 A,B: If screw purchase is not completely secure and adequate, apposition and alignment of the joint may be forced with the insertion of staple ﬁ xation.

Southerland_Chap58.indd 845 6/20/2012 3:00:30 PM 846 Part VI • Midfoot Joint Arthrodesis

Figure 58.19 A: Use of closed-suction drains. B: Layered wound closure. C: Skin incision closure. D: Jones compression dressing and short leg cast.

Figure 58.20 Postoperative radiographs.

Southerland_Chap58.indd 846 6/20/2012 3:00:33 PM Chapter 58 • Triple Arthrodesis 847

radiographs are obtained through the cast. Patient is encour- documented after triple arthrodesis. These complications can aged to perform range-of-motion exercises of the digits and be minimized with effective planning, proper technical execu- knee and hip while maintaining non-weight-bearing. tion, and sensible postoperative management. This is a time-tested and effective procedure and is a viable PHASE IV (WEEKS 10 TO 12) treatment option for various deformities and malformations. Relief of pain, improvement of function, correction of deform- Radiographs are repeated at week 10. With evidence of ade- ity, and stabilization of the rearfoot are clear indications of this quate consolidation, patient may begin partial weight-bearing procedure. with crutches or walker at week 10 to 12.

PHASE V (3 TO 6 MONTHS) REFERENCES At 3 months, the patient can begin full weight-bearing with 1. Ryerson EW. Arthrodesing operations on the foot. J Bone Joint Surg Am 1923;5:453–471. a high-top, padded boot or an elastic foot and ankle support 2. Hallgrimsson S. Studies on reconstructive and stabilizing operations on the skeleton of the stocking. The patient is able to graduate into a normal activity foot with special reference to subastragalar arthrodesis in treatment of foot deformities with aggressive physical therapy by 4 to 6 months to avoid stiff- following infantile paralysis. Acta Chir Scand 1943;78[Suppl]:1–215. 3. Hart VL. Arthrodesis of the foot in infantile paralysis. Surg Gynecol Obstet 1937;64: ness and disuse atrophy. 794–805. 4. Cole WH. Bony fi xation of the foot in infantile paralysis: subastragalar arthrodesis. J Bone Joint Surg Am 1930;12:289–298. 5. Schwartz RP. Arthrodesis of subtalus and midtarsal joints of the foot: historical review, RESULTS AND COMPLICATIONS preoperative determinations, and operative procedure. Surgery 1946;20:619–635. 6. Patterson RL, Parrish FF, Hathaway EN. Stabilizing operation on the foot: a study on the Triple arthrodesis has proven to be an excellent means of cor- indications, techniques used and end results. J Bone Joint Surg Am 1950;32:1–2. 7. Miltner L. Stabilization of the foot: a study of late results. 1931;13:502. recting deformity, reducing symptoms, providing stability, and 8. Buzby BF. Results of stabilizing operations of the feet. J Med Soc N J 1930;27:316–320. enhancing function for many conditions. Refi nements in tech- 9. Crego CH, McCarroll. A report of 1100 consecutive stabilizations in poliomyelitis. J Bone nique, instrumentation, and fi xation and better understanding Joint Surg 1938;20:609–620. 10. Guidal P, Sodemann T. Results of 256 triarticular arthrodeses of the foot in sequelae of of biomechanics allow the surgeon to provide a more reliable infantile paralysis. Acta Orthop Scand 1930;1:199–230. correction of deformity with a lower rate of complications. 11. Brown LT. The end results of stabilizing operations on the foot. J Bone Joint Surg Nonetheless, as with any procedure, complications may arise. 1924;6:839–846. 12. Whitman R. The operative treatment of paralytic talipes of the calcaneus type. Am J Med Sci Historically, pseudoarthrosis has been a common complica- 1901;122:593. tion after triple arthrodesis. In modern times, calcaneocuboid 13. Soule RE. Arthrodesis of some of the smaller joints in the treatment of paralytic and acquired deformities. JAMA 1912;58:1440. joint appears to be the primary site for delayed healing rather 14. Davis GG. The treatment of hollow foot. Am J Orthop Surg 1913;11:231. than talonavicular joint in the past. The use of two incisions 15. Hoke M. An operation for stabilizing paralytic feet. Am J Orthop Surg 1921;3:494–507. rather than a single lateral incision has likely reduced the 16. Dunn N. Calcaneo cavus and its treatment. Am J Orthop Surg 1919;1:711–721. 17. Dunn N. Stabilizing operations in the treatment of paralytic deformities of the foot. Proc R rate of talonavicular joint nonunion. Weight-bearing stresses Soc Med 1922;15:15–22. on the lateral column with early weight-bearing are the likely 18. Smith AF, von Lackum HL. Subastragaloid arthrodesis: a study of end results. Surg Gynecol reason for the more frequently encountered nonunion of the Obstet 1925;40:836–841. 19. Brewster A. Countersinking the astragalus in paralytic feet. N Engl J Med 1933;209: CCJ. The role of stable fi xation technique cannot be underes- 71–74. timated in reducing the overall incidence of nonunion. Other 20. Girard PM. Ankle joint stabilization with motion. J Bone Joint Surg Am 1935;17:802–806. 21. Ombredanne L. Les arthrodeses du pied. Rev Orthop 1921;8:515–576. complications including recurrence of deformity, degenerative 22. MacAusland WB. Subastragalar arthrodesis. Arch Surg 1929;18:624. arthrosis in adjacent joints, and avascular necrosis have been 23. Friedland M. Method of arthrodesis of tarsus. Arch Orthop 1929;27:240.

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