SUB-TALAR AND TRIPLE ARTHRODESIS
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1 SUB-TALAR AND TRIPLE ARTHRODESIS J de Halleux With the members of Education Committee
2 INDICATIONS ARTHRITIS OF THE SUB-TALAR AND/OR MID-TARSAL JOINTS RIGID VARUS OR VALGUS DEFORMITY OF THE HIND-FOOT COALITIONS SEVERE INSTABILITY OF THE HIND-FOOT
3 SUB-TALAR ARTHRODESIS PATIENT IN LATERAL OPPOSITE POSITION
4 INCISION FROM THE TIP OF THE FIBULA OVERLYING THE SINUS TARSI UP TO CALCANEO-CUBOID JOINT
5 EXCISION OF THE SINUS TARSI SOFT TISSUES
6 OPENING OF THE JOINT lamina spreader bulk under medial malleolus to stress the foot in varus and to facilitate the opening
7 REMOVAL OF CARTILAGE AND BONE ACCORDING WITH THE DEFORMIITY CHISEL CURRETTE BURR FHL!!
8 REDUCTION + FIXATION 5/10 VALGUS Direction 1 or 2 screws Type
9 CANNULATED SCREWS FREEHAND FLUOROSCAN
10 A.O. ICOS
11 OUTCOME OF CALCANEAL FRACTURE Reduction of calcaneous high Reduction of tibio-talar angle (n.v. ~ 120 ) Anterior impingement of ankle joint
12 DISTRACTION BONE BLOCK FUSION Bone graft from femoral head ( Carr 1988 )
13 TRIPLE ARTHRODESIS SUPPINE POSITION FIRST STEP (sandbag underneath the ipsilateral buttock the medial malleolus) Sub-talar joint +/- calcaneo-cuboid joint SECOND STEP Talo-navicular joint
14 OPTIMAL POSITION FOR FUSION Subtalar joint = 5 to 10 valgus Rotate transverse tarsal joint into a plantigrade position!no forefoot varus/suppination position!
15 SURGICAL TECHNIQUE : 1 Step (ST +/- CC) - Lateral incision (tip fibula to base MT4) - Sural nerve inferiorly - Fib Sup nerve superiorly Pathologie du Pied et de la Cheville, Th Leemrijse et B Valtin, 2009
16 Remove articular cartilage from the subtalar joint ( anterior and posterior facets)! FHL in the posteromedial subtalar joint
17 SURGICAL TECHNIQUE : 2 Step (TN) Antero medial approach between Tib Ant /EHL Hinterman distractor Distraction TN More extensive if lateral column lengthening (PPV)
18 DO WE NEED TO STABILISE THE CALCANEO-CUBOIDAL JOINT? Effect of isolated hindfoot arthrodesis Type of arthrodesis Diminution ROM subtalar Diminution ROM TN Diminution ROM CC Diminution ROM TT subtalar 100% 26% 56% 13 loss Talonavicular Calcaneocuboidal >60% 100% >90% loss 15-35% % 100%? Astion DJ and all, Motion of the hindfoot after simulated arthrodesis, JBJS Am, 1997
19 CC ARTHRODESIS only if: - painful CC arthritis - need for lateral column shortening or lenghtening REMOVAL OF CARTILAGE AND BONE ACCORDING WITH THE DEFORMIITY PPV + abduction FF lateral column lengthening PCV + adduction FF lateral column shortening
20 REDUCTION + temporary STABILISATION 1 = TN JOINT - TN = Key joint to allow excellent correction of the 3 joints - Rotate transverse tarsal joint into a plantigrade position!no forefoot varus/suppination position! - PPV = Forefoot plantar flexion + adduction
21 REDUCTION + temporary STABILISATION 2 = TC JOINT - Subtalar joint = 5 to 10 valgus
22 Talo Navicular Screws 2 canulated screw 4,5 mm Talo Calcaneal screw 1 or 2 cannulated screws 6,5 / 7,0 mm
23
24 Auto - & allografts?
25 peroperative difficulty to correct hindfoot deformitie Achilles Tendon tightness lengthening Transverse incision fascia gastrocnemius Foot is suppinated and dorsiflexed to have elongation
26 Additional procedures? If hindfoot deformity is associated to the bone morphology : additional osteotomies of the calcaneus Valgus : Myerson Varus : Dwyer type If instability of the first column : arthrodesis of the medial column If insufficiency of medial collateral ligament = additional procedures mandatory
27 Example : Pes planovalgus treated by subtalar joint arthrodesis, remaining valgus deformity due to the insuffiency of the medial collateral ligament
28 R/ medial ligamentoplasty triple arthrodesis calcaneal osteotomy Myerson
29 ARTHROSCOPIC TECHNIQUE LIMITED INDICATIONS NO DEFORMITY CORRECTION
30 30 THANK YOU!!!
31
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