Professional Documents
Culture Documents
20
TECHNICAL CONSIDERATIONS
SOFT TISSUE CONSIDERATIONS
SURGICAL PRINCIPLES
COMPLICATIONS
SPECIFIC ARTHRODESES (video clips
11-14)
TECHNICAL CONSIDERATIONS
The two basic types of arthrodeses are an in situ fusion
and one that corrects a deformity. In an in situ fusion,
positioning the foot or ankle is usually not difficult because no deformity is present. In a deformity1087
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PART V
CHAPTER 20
SURGICAL PRINCIPLES
When carrying out an arthrodesis of the foot and
ankle, the following surgical principles should be carefully observed:
A well-planned incision of adequate length to
avoid undue tension on the skin edges.
An attempt should be made to create broad, congruent cancellous surfaces that can be placed into
apposition to permit an arthrodesis to occur.
The arthrodesis site should be stabilized with
rigid internal fixation. This sometimes depends
on the surgeons ingenuity in creating a rigid
construct, particularly if poor bone stock is
present.
When performing a fusion, the hindfoot must be
aligned to the lower extremity and the forefoot to
the hindfoot to create a plantigrade foot.
After exposure of the fusion site, the soft tissues surrounding the joints are removed. This mobilizes the
joints, allowing the surgeon to realign the foot. At
times, because of previous trauma or severe malalignment, mobilization of the joints is not possible and
bone resection needs to be carried out. In my experience, however, the majority of cases can be aligned,
even when a significant deformity is present, by complete mobilization of the involved joints followed by
manipulation to create a plantigrade foot.
Once the joints have been mobilized and it is determined that bone does not need to be removed, the
articular surfaces are meticulously debrided of their
1089
articular cartilage and any fibrous tissue to subchondral bone. This is achieved with a curet or a small,
sharp osteotome. A lamina spreader or a towel clip can
facilitate distraction of the articular surfaces, making
the debridement easier, but this can damage the bone
if it is soft.
Once the subchondral bone is exposed, the foot is
once again manipulated, placing it into the desired
alignment. If this is achievable, internal fixation can be
inserted. If large amounts of bone need to be removed
to create a plantigrade foot, this should be done before
removing the articular cartilage. The subchondral surfaces are heavily feathered or scaled with a 4- or 6-mm
osteotome, which creates a broader, bleeding cancellous surface required for successful fusion. The articular surfaces to be arthrodesed are brought together and
stabilized with provisional fixation. Then interfragmentary compression is achieved using appropriate
definitive fixation.
By carrying out a fusion in this manner, broad bleeding surfaces of cancellous bone are brought together,
which provides the best possible chance for a successful arthrodesis. In my experience, bone graft from the
iliac crest is rarely necessary when carrying out an
arthrodesis. Sometimes bone has been lost, making a
bone graft necessary, but in an in situ fusion, grafting
is not usually required. If a small amount of bone is
needed, it can be harvested from the calcaneus, medial
malleolus, or proximal medial tibia without violating
the iliac crest and causing its attendant morbidity.
Likewise, bone substitutes or other materials are rarely
required if the bone preparation is carried out correctly.
For internal fixation, I prefer an interfragmentary
screw that compresses the joint surfaces. At times a
power staple, a plain staple, or a plate may be used.
Although an external fixator can provide excellent fixation, if possible a closed system without an external
fixator is safer due to possible pin tract problems with
prolonged immobilization. Because of soft bone or
soft tissue problems, however, it may become necessary to use an external fixator. Under these circumstances this device provides excellent rigid fixation.
The skin closure after a fusion is very critical. The
surgeon should always attempt, if possible, to obtain
a soft tissue cover underneath the skin flaps, such as
fat or muscle. This is important because if a superficial
wound slough occurs, it will be over an underlying bed
of soft tissue rather than bone. This is not always possible, particularly on the dorsum of the foot, where
bone lies directly beneath the skin. If any tension is
noticeable on the skin edge, some type of a relaxing
skin suture should be used. A drain is always useful if
profuse bleeding is anticipated.
The initial postoperative dressing is very important
and should support the soft tissues as well as the
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PART V
COMPLICATIONS
The main complications after an attempted arthrodesis include infection, skin slough, nerve disruption or
entrapment, nonunion, and malalignment.
The possibility of infection is always a postsurgical
concern. During surgery, antibiotic irrigation as well as
parenteral antibiotics can help minimize this complication. Good surgical technique with careful handling
of the tissues, removal of devitalized tissue, and prevention of hematoma formation also play an important role in minimizing the possibility of infection. If
an infection occurs, it is important to recognize and
treat it promptly with appropriate antibiotics.
A skin slough around the foot and ankle can present
a difficult management problem because of the lack of
adequate subcutaneous tissue. The potential for a skin
slough can be minimized by creating full-thickness
skin flaps, making incisions of adequate length to minimize tension on the skin edges, using postoperative
drainage when appropriate, and applying a firm compression dressing postoperatively. Placing a patient
into a cast without adequate padding is not advisable.
When a skin slough occurs, it is important to treat it
vigorously with local debridement and application of
wet-to-dry dressings to promote granulation tissue,
followed by coverage with a split-thickness skin graft.
Vacuum-assisted closure (wound-VAC) can be extremely
useful to manage a wound slough. If the slough is too
large, a plastic surgeon should be consulted.
Nerve disruption or entrapment around the foot and
ankle not only creates numbness but also can cause
chronic pain from footwear rubbing against the
neuroma. A carefully planned surgical approach is the
best treatment, but if a symptomatic neuroma occurs,
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SPECIFIC ARTHRODESES
Much has been written about arthrodesis of the foot
and ankle. Many surgical approaches, site preparations, and types of internal and external fixation have
been proposed. This section presents the techniques I
have evolved over time and that result in a satisfactory
outcome with careful adherence to technique. Other
techniques may be equally effective, but reproducibly
good results have been achieved with subtalar
arthrodesis, talonavicular arthrodesis, double arthrodesis, triple arthrodesis, naviculocuneiform arthrodesis, and tarsometatarsal arthrodesis.
SUBTALAR ARTHRODESIS
An isolated subtalar joint arthrodesis results in
satisfactory correction of deformity and relief of
pain that enables the patient to regain the
ability to perform most activities. Of the hindfoot fusions, the patients ability to achieve a
high level of function is greatest after a subtalar
arthrodesis. Biomechanically, the position of the
subtalar joint determines the flexibility of the
transverse tarsal (talonavicularcalcaneocuboid)
joint, and therefore it is imperative that a subtalar arthrodesis be positioned in about 5
degrees of valgus to permit mobility of the
transverse tarsal joint. If it is placed in varus, the
transverse tarsal joint is locked, and the patient
tends to walk on the lateral side of the foot. The
posture of the forefoot also needs to be considered because if there is more than 10 to 12
degrees of fixed forefoot varus, after a subtalar
arthrodesis the patient cannot compensate for
this deformity and walks on the lateral side of
the foot, resulting in discomfort beneath the
fifth metatarsal head or base, or both, and in
severe stress on the lateral ankle ligaments.
Occasionally the fixed forefoot varus can be corrected by carrying out a simultaneous naviculocuneiform fusion.
Base fourth
metatarsal
Fibula
Incision
Calcaneocuboid joint
A1
A2
D1
D2
Figure 201 Subtalar joint fusion. A, Site of fusion. Incision is made from the tip of the fibula and extends toward the base of
the fourth metatarsal so as to place it in the interval between a branch of the superficial peroneal nerve dorsally and the sural
nerve plantarly. B, Exposure of subtalar joint with Weitlaner retractor. C, A lamina spreader placed within the sinus tarsi area
exposes the posterior and middle facets. D, When a screw is used for fixation of the subtalar joint, it is placed through the posterior facet into the neck of the talus. Circle in the posterior facet (PF) demonstrates where the tine of the guide is placed in
order to accurately place the screw. MF identifies the middle facet. The anterior cruciate guide is placed into the subtalar joint
with the tine in posterior facet, as marked on the model. The guide is then set on the heel, after which a guide pin is placed
across the subtalar joint. E, Preoperative and postoperative radiographs demonstrate subtalar fusion using a 7.0-mm screw. The
screw begins off the weight-bearing area of the heel. F, Preoperative and postoperative radiographs demonstrate subtalar
arthrodesis after calcaneal fracture. Interpositional bone graft is used to reestablish the talocalcaneal relationship. Interpositional
bone graft is rarely required to obtain a satisfactory result. G, When lateral subluxation of the subtalar joint is present, the joint
must be reduced and not fused in situ. The lateral aspect of the calcaneus should line up with the lateral aspect of the talus. H,
Example of in situ fusion with persistent lateral subluxation of the subtalar joint, resulting in subfibular impingement and persistent pain. I, Preoperative and postoperative radiographs demonstrating subtalar fusion in a patient with prior ankle fusion who
developed arthrosis of the subtalar joint.
1092
E1
E2
F1
F2
I1
I2
Figure 201contd
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CHAPTER 20
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PART V
TALONAVICULAR ARTHRODESIS
Surgical Technique
Indications
The most common indication for an isolated
talonavicular arthrodesis is primary arthrosis,
arthrosis secondary to trauma,20 or rheumatoid
arthritis.18 With instability of the talonavicular
joint secondary to dysfunction of the posterior
tibial tendon or collapse of the talonavicular
joint from rupture of the spring ligament, an isolated talonavicular arthrodesis can be considered. In these circumstances, however, I usually
carry out a double or triple arthrodesis.
Alignment of the Fusion
The alignment of the normal foot is observed to
determine the alignment of the affected side.
The positioning of an isolated talonavicular
arthrodesis is very important, because the subtalar and calcaneocuboid joint motion is greatly
restricted after this arthrodesis. Therefore the
hindfoot and forefoot must be aligned into a
plantigrade position; if not, a nonplantigrade
foot will be created and may be symptomatic.
The subtalar joint should be placed into 5
degrees of valgus, the talonavicular joint into
neutral, and the forefoot into 0 to 5 degrees of
forefoot varus (Fig. 202A).
CHAPTER 20
Flatfoot deformity
1099
A1
A2
Figure 202 Talonavicular arthrodesis. A, Radiograph and diagram demonstrate changes that occur in the talonavicular joint
with flatfoot deformity. The head of the talus deviates medially as the forefoot deviates laterally into abduction. The diagram
demonstrates abnormal alignment brought about by flatfoot deformity and its subsequent correction. The navicular is once again
centered over the head of the talus. B, Exposure of the talonavicular joint through a medial incision. The Freer elevator points
to the naviculocuneiform joint. C, Access is gained to the talonavicular joint by distracting the joint with a towel clip.
1100
11.
12.
13.
14.
PART V
Figure 203 Preoperative and postoperative radiographs demonstrate talonavicular arthrodesis using a 7.0-mm cannulated
screw. Note the congenital hallux varus.
CHAPTER 20
DOUBLE ARTHRODESIS
The double arthrodesis as described by
DuVries23 consists of a fusion of the talonavicular and calcaneocuboid joints.17,24 It is based on
the biomechanical principle that if the motion in
the talonavicular and calcaneocuboid joints is
eliminated, no motion occurs in the subtalar
joint. This results in the same degree of immobilization as a triple arthrodesis, but without
the necessity of completing the subtalar
portion. A double arthrodesis takes less time
and probably has less patient morbidity because
the subtalar joint is not included in the fusion
mass.
Indications
The double arthrodesis is indicated when the
malalignment involves the transverse tarsal joint
or forefoot, or both. It is most often carried
out for patients with posterior tibial tendon dysfunction who are not candidates for a tendon reconstruction or subtalar fusion. In these
patients, the subtalar joint is flexible and no
subtalar disorder is present. There is also a
1101
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4.
5.
6.
7.
8.
9.
10.
11.
12.
PART V
the fourth metatarsal, and extends proximally toward the tip of the fibula, stopping
about 1 cm short of the tip.
The incision is deepened to the extensor
digitorum brevis muscle. Care is taken to
identify any anterior branch of the sural
nerve that might be crossing the surgical
field.
The capsule of the extensor digitorum
brevis is opened, its origin is released, and
the muscle is reflected distally about 1 cm
distal to the calcaneocuboid joint.
The calcaneocuboid joint is identified and
the soft tissue stripped plantarward and
dorsally using a periosteal elevator.
The articular cartilage is removed from the
calcaneocuboid joint as thoroughly as possible using a small, sharp osteotome or
curet.
Placing a deep retractor into the wound
along the dorsal aspect, the surgeon identifies the lateral aspect of the talonavicular
joint opposite the calcaneocuboid joint
and removes articular cartilage if possible.
Usually, cartilage can be removed from the
lateral third of the talar head and occasionally from the navicular, depending on how
tight the foot is.
The medial approach is through a longitudinal incision, starting at the tip of the
medial malleolus and carried distally 1 cm
past the naviculocuneiform joint (see Fig.
202B).
The incision is deepened through the capsular tissues, after which the capsule and
spring ligament are stripped from the navicular. An elevator is passed over the dorsal
aspect of the talonavicular joint, completely
freeing the joint.
Using a towel clip embedded into the proximal portion of the navicular, the surgeon
distracts the talonavicular joint by pulling
the foot in an adducted position and longitudinally (see Fig. 202C). If the quality
of the bone is adequate, a small lamina
spreader is useful to gain exposure.
The articular cartilage is removed from the
talonavicular joint with an osteotome or
curet. Sometimes removing the cartilage is
difficult, and it is important to be sure that
the joint capsule has been completely
stripped from the talonavicular joint to facilitate exposure.
13. The foot is manipulated into proper alignment to determine whether any bone needs
to be removed from the attempted fusion
site, which generally is not necessary. However, it is important to be sure no gap is
created at the calcaneocuboid joint when the
foot is brought into a plantigrade position.
14. To correct a severe forefoot varus deformity,
the navicular must be plantar flexed on the
head of the talus. This is carried out by
holding the hindfoot in one hand and rotating the forefoot in such a way as to plantar
flex the navicular on the head of the talus
while simultaneously adducting the foot.
This maneuver corrects the deformity and
creates a plantigrade foot.
15. With the foot held in a plantigrade position, the calcaneocuboid joint is observed
because if it is distracted, some bone needs
to be removed from the talar head. This
does not occur often, but again, it is important that a gap is not created between the
calcaneus and cuboid.
16. Before placing the internal fixation, the
bone ends are heavily scaled using a 4-mm
osteotome. The talonavicular joint must be
well feathered from both medial and lateral
sides to ensure that the greatest amount of
bone surface has been destroyed to help
prevent a nonunion.
17. Many ways are available to carry out internal
fixation for a double arthrodesis. If adequate
bone stock exists, two 4.0-mm cannulated
screws across the talonavicular joint provides
excellent internal fixation. A single 7.0-mm
screw can be used in a large patient, but in
a smaller person or a person with soft bone,
it can result in a fracture of the medial side
of the navicular (Fig. 204A to C).
18. The foot is then manipulated into proper
alignment as described earlier; and the
guide pin for the 4.0-mm cannulated screw
is placed across the talonavicular joint.
19. The guide pin is started at the distal end of
the navicular at the naviculocuneiform joint.
If one starts at the midportion of the navicular, insufficient bone may be present along
the medial side of the navicular, and a fracture of the medial aspect of the navicular
can occur. The surgeon should attempt to
incorporate as much of the medial aspect
of the navicular as possible with the screw.
The placement is usually checked with
B3
B1
B2
C2
C1
D1
D2
Figure 204 A, Diagram of double arthrodesis. B, Preoperative and postoperative radiographs demonstrating arthrodesis using
7-0 mm cannulated screws. C, Double arthrodesis using a cannulated screw for the talonavicular joint and power staples for the
calcaneocuboid joint. D, Double arthrodesis using power staples in both the talonavicular and calcaneocuboid joints. This is
done when the bone is soft, particularly in a patient with rheumatoid arthritis. Note the arrangement of staples around the joint
to gain maximum stabilization.
Continued
1103
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PART V
E2
E1
F1
F2
G3
G1
G2
G4
Figure 204contd E, Radiographs demonstrate failed double arthrodesis secondary to fracture of the talonavicular screw.
F, Revision of double arthrodesis to a triple arthrodesis. G, Preoperative and postoperative radiographs demonstrate the correction that can be obtained with double arthrodesis in a patient with an acquired flatfoot secondary to posterior tibial tendon
dysfunction.
CHAPTER 20
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PART V
Figure 205 Technique for slot graft to correct disruption of tarsal joints. A, Outline of slot graft extending from the talus into
the metatarsal bones. B, Preoperative and postoperative radiographs demonstrate placement of the bone block, which is held
in place with two 4.0-mm screws, and fusion of the calcaneocuboid joint to help reinforce the fusion site. Preoperative and postoperative anteroposterior (C) and oblique (D) radiographs demonstrate placement and incorporation of the bone block.
CHAPTER 20
TRIPLE ARTHRODESIS
1107
D1
D3
C1
B1
D2
D4
B2
C2
Figure 206 Triple arthrodesis, methods of internal fixation. A, Diagram of triple arthrodesis. B, Postoperative radiograph
demonstrating triple arthrodesis with anatomic restoration of foot posture. C, Triple arthrodesis using 7.0-mm cannulated screws
for the subtalar and talonavicular joints and multiple power staples for the calcaneocuboid joint. D, Correction of severe hindfoot deformity secondary to long-standing posterior tibial tendon dysfunction with restoration of the longitudinal arch using a
7.0-mm cannulated screw for the subtalar joint and power staples for the talonavicular and calcaneocuboid joints. Note that the
height of the longitudinal arch has been restored and severe abduction of the foot is corrected.
1108
PART V
CHAPTER 20
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
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24.
25.
26.
27.
PART V
Postoperative Care
In the recovery room, a popliteal block is administered to control the immediate postoperative
pain. The patients initial surgical cast is changed
10 to 14 days after surgery, and the sutures are
removed if appropriate. The patient is placed
into a short-leg removable cast with an elastic
bandage to control edema and is kept non
weight bearing for 6 weeks. Then radiographs
are obtained, and if satisfactory union is occurring, the patient is permitted to bear weight as
tolerated in the removable cast.
Twelve weeks after surgery, radiographs are
again obtained, and if a fusion has occurred,
the patient wears an elastic stocking and is
permitted to bear weight as tolerated. If the
fusion is somewhat tenuous, the patient is asked
to walk around the house without the cast and
use it outside for another month (Fig. 206B
to D).
Complications
The most frequent complication after a triple
arthrodesis is a nonunion of one of the fusion
sites, most often the talonavicular joint, probably because its exposure is more difficult and the
bone may be sclerotic. If a nonunion occurs and
is not symptomatic, no treatment is indicated.
Occasionally after a triple arthrodesis, if two of
the three joints have fused, the joint with a
nonunion is asymptomatic. If a painful nonunion
is present but the alignment of the extremity is
satisfactory, some type of an inlay bone block
CHAPTER 20
1111
Authors Experience
We have reviewed two groups of patients after
triple arthrodesis.30,34 The first group involved 29
fusions in 27 patients (23 women, 4 men) for
treatment of posterior tibial tendon dysfunction.
The average age was 62 years (range, 44 to 78
years), and average follow-up was 55 months
(range, 24 to 122 months). The preoperative
AOFAS score was 30, which improved postoperatively to 80. One nonunion of the talonavicular joint occurred and was asymptomatic.
The AP radiographs demonstrated that the
talarfirst metatarsal angle improved from
24 to 10 degrees postoperatively and the
talarsecond metatarsal angle from 35 to 19
degrees. In the lateral radiograph the talar
first metatarsal angle improved from 18 to 9
degrees. In all cases the final correction was
greater than the contralateral foot if it was not
pathologic. The radiographs further demonstrated an increase in the arthrosis in the ankle
joint in 10 of 29 cases (33%), in the naviculocuneiform joint in five (17%), and at the tarsometatarsal joint in four (14%) (Fig. 207A
and B).
A second group consisted of 17 patients (12
women, 5 men) and 18 feet, with an average
age of 66 years (range, 52 to 80 years ). They
were evaluated to determine the effect of a
triple arthrodesis in the older age group,
because no paper had previously addressed this
in the literature.30 The etiology was posterior tibial tendon dysfunction in 10 patients,
rheumatoid arthritis in three (four feet), diabetes
mellitus in one, poliomyelitis in one, trauma in
one, and poststroke effects in one. The followup was 42 months (range, 27 to 156 months).
The procedure was carried out because of pain,
deformity, or both. The pain level preoperatively
was 4 on a scale of 5 and postoperatively
was 1.
Fourteen patients (15 feet) were satisfied
because of the improved position and diminished pain. Interestingly, however, 11 patients
still thought they had some pain in the foot,
but it was not sufficiently symptomatic for them
to be dissatisfied with the procedure. Of the
three patients who were dissatisfied, two had
a valgus alignment of the heel that resulted
in pain. The patients observed that the time
from surgery to maximum relief was about 10
months.
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PART V
and two at the calcaneocuboid joint, one requiring revision and one being asymptomatic.
In summary, the triple arthrodesis is an excellent procedure for correcting a fixed deformity
of the foot, but it should be used judiciously,
particularly in the younger patient, and only
when a lesser procedure cannot be used.
NAVICULOCUNEIFORM ARTHRODESIS
A naviculocuneiform arthrodesis is usually
carried out for arthrosis of one or more of the
articulations as a result of primary arthrosis or
secondary to trauma. The other reason to carry
out this arthrodesis is in the patient with posterior tibial tendon dysfunction and a fixed forefoot varus deformity so that a more extensive
hindfoot fusion can be avoided.
In the patient with a fixed uncorrectable
forefoot varus deformity, a double or triple
arthrodesis is indicated because an isolated subtalar arthrodesis would cause the patient to walk
on the lateral border of the foot. If the fixed fore-
CHAPTER 20
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PART V
Postoperative Care
A popliteal block is administered by anesthesia
to control postoperative pain. The postoperative dressing is changed in 10 to 14 days,
sutures are removed, and the patient is placed
into a short-leg removable cast with an elastic
bandage to control swelling. Weight bearing is
not permitted until 6 weeks after surgery. At 6
weeks following surgery, if x-rays demonstrate
early union, the patient is permitted to bear
weight as tolerated in a short-leg removable
cast. As a general rule, the arthrodesis occurs
after about 3 months.
Complications
Nonunion of the naviculocuneiform joints does
occur, but by including at least the first and
second joints along with the internal fixation
passing from the tubercle of the navicular into
the cuneiforms, satisfactory union seems to
occur in most cases (Fig. 208).
The other complication is incomplete correction of the fixed forefoot varus in the patient
with posterior tibial tendon dysfunction. If
malalignment is still present and results in
a nonplantigrade foot, a double or triple
arthrodesis might be necessary to create a
plantigrade foot.
TARSOMETATARSAL ARTHRODESIS
Arthrodesis of the tarsometatarsal joints can
involve an isolated joint, usually the second or
third, or it can involve multiple joints, depending on the etiology of the arthrosis. As a general
rule, patients with primary arthroses usually have
fewer joints that require fusing than those with
post-traumatic arthrosis. In our study of 41 feet,
we observed that the patient with posttraumatic arthrosis had an average of six joints
fused per foot, compared with four joints per
foot in the primary arthrosis group.41
CHAPTER 20
1115
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PART V
Figure 209 A, Lateral incision used to expose lateral Lisfrancs joint. B, Postoperative photograph demonstrating dorsal and
dorsal-medial incision.
5.
6.
7.
8.
9.
CHAPTER 20
13.
14.
15.
16.
A1
1117
A2
B1
B2
Figure 2010 Tarsometatarsal arthrodesis. A, Preoperative and postoperative radiographs demonstrate arthrodesis of the first
metatarsocuneiform (MTC) joint using two 4.0-mm cannulated screws. This method gives excellent internal fixation. Note the
subtalar fusion as well. B, Preoperative and postoperative radiographs demonstrate arthrodesis at the first MTC joint with two
crossed screws. Note that the deformity has been significantly improved, although not totally corrected, by the arthrodesis.
1118
PART V
Figure 2011 Preoperative (top) and postoperative (bottom) radiographs demonstrate isolated arthrodesis (arrows) of second
metatarsocuneiform joint. (From Mann RA, Coughlin MJ: The Video Textbook of Foot and Ankle Surgery. St. Louis, Medical Video
Productions, 1991.)
CHAPTER 20
1119
A
Figure 2012 Midfoot arthrodesis of multiple joints. A, Preoperative and postoperative radiographs of intertarsal arthrodesis
for degenerative arthrosis. Note that the screw pattern locks navicular to the cuneiforms; also note the intercuneiform screws. If
the tarsometatarsal joints are not involved, the arthrodesis does not need to include them.
Continued
1120
PART V
C1
B1
B2
C2
E1
D1
D2
E2
Figure 2012contd B and C, Preoperative (1) and postoperative (2) radiographs demonstrate arthrodesis of tarsometatarsal
joints 1, 2, and 3, along with cuneiforms using a four-screw pattern. Note the correction of deformity in both the anteroposterior and lateral planes. D and E, Preoperative (1) and postoperative (2) radiographs demonstrate arthrodesis of tarsometatarsal
joints 1, 2, and 3, along with intercuneiform joints using a six-screw pattern. The number of screws used depends on the stability of fixation needed to obtain rigid fixation. Note the correction of deformity in both the anteroposterior and lateral planes.
CHAPTER 20
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PART V
REFERENCES
Subtalar Arthrodesis
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