0198-0211/92/1307-0408$03.00/0 FOOT
& ANKLE
Copyright © 1992 by the American Orthopaedic Foot and Ankle Society, Inc.
Triple Arthrodesis through a Single Lateral Approach: A Cadaveric Experiment* James V. Bono, M.D.,t and Richard L. Jacobs, M.D.:j: Albany, New York
ABSTRACT Using a single lateral approach, triple arthrodesis was performed on six cadaveric feet. An attempt was made to obliterate the talocalcaneal, talonavicular, and calcaneocuboid joints. The limbs were subsequently disarticulated to allow for an inspection of the talonavicular, talocalcaneal, and calcaneocuboid joints. An estimate of cartilage and subchondral bone removed from each articular surface was made by a single observer (J.V.B.) by direct visual inspection. Results were as follows: calcaneocuboid joint, 90% of cartilage removed; talocalcaneal joint, 80% of cartilage removed; talonavicular joint, 38% of cartilage removed. Failures at the talonavicular joint were attributed to a poor appreciation of the anatomy of the talar head and poor observation. Complications involved in obliteration of the talonavicular joint from a single lateral approach included: inadvertent division of the talar neck; inadvertent division of the talar head; removal of excessive bone stock; medial skin punctures; and creation of an iatrogenic cut through the talar dome. Therefore, a triple arthrodesis through a single lateral approach, as described by Ryerson,8 Hoke," and Campbell,2 cannot be recommended. The talonavicular joint should be approached through an auxiliary medial incision, as recommended by cracchlclc," This paper documents the experience of a beginner with this operation, and demonstrates the value of using the anatomy laboratory.
desis operation and reflects the learning curve associated with this procedure. By demonstrating the problems that an inexperienced surgeon can encounter, one may be able to identify the errors in procedure that contribute directly to a failed triple arthrodesis. We have attempted to study the effectiveness of this surgical procedure, performed by a resident in the anatomy laboratory, through a single lateral approach.
MATERIALS AND METHODS
Six cadaveric limbs were procured. A single straight incision, centered over the sinus tarsi, was carried down through skin, fascia, and subcutaneous tissues. The incision was extended from the peroneal tendons and directed anteriorly toward the head of the talus, and ended at the lateral border of the extensor tendons. The contents of the sinus tarsi were evacuated and the origin of the extensor digitorum brevis muscle was retracted distally. The capsules of the calcaneocuboid and talonavicular joint were incised, and the articular surfaces were obliterated with an osteotome. Similarly, the posterior facet of the talocalcaneal joint was identified just medial to the peroneal tendons and was obliterated. The procedure on all six limbs was carried out by one author (J.v.B.). At the completion of the experiment, the limbs were disarticulated to allow for inspection of the talonavicular, talocalcaneal, and calcaneocuboid joints.
INTRODUCTION
Triple arthrodesis through a single lateral approach is a technique that requires experience to do properly. This study represents a resident's (J.V.B.) experience in the anatomy laboratory rehearsing the triple arthro-
RESULTS
* This paper was presented at the American Academy of Orthopaedic Surgeons Meeting, Washington, DC, February, 1992 (poster exhibit). t Senior Resident, Division of Orthopaedic Surgery, Albany Medical College, Albany, New York :j: Professor and Chief, Division of Orthopaedic Surgery, Albany Medical College. To whom requests for reprints should be addressed at Division of Orthopaedic Surgery, Albany Medical College, Albany, New York 12208.
Ninety percent of articular cartilage was denuded from the calcaneocuboid joint space (Table 1). However, in 66% of these limbs, there was excessive removal of bone stock, which left a large dead space (Fig. 1). (This complication appeared in the first four cadaveric limbs dissected and was not present in the final 408
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409
TABLE 1
Estimated Results of Foot
Joint surface
18
L
Proximal
2
R
Distal Proximal Distal . Proximal
4
R
Distal Proximal
5
L
Distal Proximal
6
R
Distal Proximal Distal
Removed at Each Joint
Talonavicular
Talocalcaneal
Calcaneocuboid
Neck of talus transected inadvertently 0 0 Head of talus transected 50 40 Inferior Dome of talus cut with osteotome with injury to tibial piafond 100 b 100 Good contour Head of talus cut 100 15 Head of talus cut 50 0 Head of talus cut 0 Missed 0
100
100 b
100 40 c
75 with fragmentation b 100 b
60 c 100 b
100 with fragmentation b 100 b
90 b 100 b
100 b .• 100 b
100 b 20'
100
100 50'
100 75
100
75 b
50
Extension of incision proximally. allowing translocation of peroneal tendons to reach posterior facet. This was found to be unnecessary. Excessive bone loss. c Posterior facet saddle shaped-inclines. then declines. Failure to appreciate contour of joint. (Inclined segment denuded and declining segment untouched.) d Medial skin over talonavicular joint punctured four times . • Disruption of peroneus longus tendon. , Not denuded down to subchondral bone. a
b
Fig. 1. Limb 6. Top arrow shows intact talonavicular joint. Osteotomy occurred across talar head proximal to talonavicular joint. Bottom arrow shows remaining cartilage of calcaneocuboid joint. Excessive removal of bone can create dead space.
two specimens, reflecting the learning curve involved with this operation). In one limb, excessive debridement of the calcaneocuboid joint was found to have disrupted the peroneus longus tendon where it courses under the cuboid (Figs. 1 and 2). The talocalcaneal joint proved to be slightly more difficult to obliterate than the calcaneocuboid joint, with 80% of the total joint surfaces denuded (Fig. 3). When the posterior facet of the calcaneus was examined, 90% of this articular surface was denuded, as compared with 70% of the articular surface of the posterior facet of the talus. In two limbs, the articular surface of the posterior facet of the talus had been debrided superficial to subchondral bone and was inadequate for the purposes of fusion. In limb 2, the posterior facet was saddle shaped, with an inclining anterior slope and a declining posterior slope; the convex nature of the posterior articular facet, as described by Jahss" and others,1,4,7,9 was especially pronounced. In this limb, only the inclining anterior portion of the posterior facet was obliterated (Fig. 3, A and B). In one third of the
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Fig. 2. A, a, Limb 5. Talonavicular joint. Osteotomy occurred across talar head, proximal to joint (top arrow). Note course of peroneal tendons across calcaneocuboid joint (bottom arrow).
limbs, there was excessive removal of bone stock of the talocalcaneal joint, which created a large dead space. The talonavicular joint showed the poorest results, with only about 40% of the articular cartilage denuded from the joint (Figs. 1-6). In limbs 5 and 6, the entire talonavicular joint was intact, despite what was thought to be a complete obliteration. An average of 50% of the articular surface of the head of the talus was denuded. However, in all six instances, the neck or head of the talus had been cut in a plane not parallel to the joint surface. In four out of six limbs, the head of the talus was partially transected. In limb 1, the neck of the talus had been transected. In limb 3, the osteotome had passed through the dome of the talus with
Fig. 3. A, B, Limb 2. Intact cartilage of navicular (top arrow) and posterior facet of the calcaneus (bottom arrow).
injury to the tibial plafond; this arose due to excessive bone stock removal of the posterior facet of the talus. The osteotome used to obliterate the joint space along the posterior facet had been sloped too severely, thereby cutting through the superior dome of the talus. In limb 3, there were also four discrete stab wounds over the medial skin about the talonavicular joint. The osteotomes introduced from the lateral approach violated the medial skin envelope.
DISCUSSION
Through a single lateral approach, the contents of the sinus tarsi were identified and evacuated easily. Extending the incision beyond the extensor tendons
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Foot & Ankle/Vol. 13, No. 7/September 1992
TRIPLE ARTHRODESIS
411
Fig. 4. A, e, Limb 4. Cartilage remaining in midtarsal joint and spring ligament. Arrow shows intact cartilage of navicular.
Fig. 5. A,
medially or over the peroneal tendons laterally offered no advantage. Inspection of the floor of the sinus tarsi was the key to the entire operation. The subtalar joint was readily identified, just medial to the peroneal tendons, by its sharp anterior slope. It was not necessary to incise the peroneal sheath or translocate the peroneal tendons in order to access this joint. When denuding the subtalar joint, one should be careful not to incline the osteotome too sharply, for fear of cutting superiorly through the dome of the talus. In two specimens, insufficient bone stock was removed (superficial to subchondral bone), whereas in four specimens, excessive bone stock had been removed, which resulted in a large dead space. An appreciation of the slope of the posterior facet is essential to achieve a successful fusion.
The calcaneocuboid joint is the simplest of all three joints to obliterate in every way. However, excessive debridement of the joint in one situation led to disruption of the peroneus longus tendon, and in three limbs, it led to removal of excessive bone stock. The results at the calcaneocuboid joint were the best, with 90% of the articular surface removed. The majority of complications occurred at the talonavicular joint. This is a direct result of the poor accessibility of this joint from a single lateral approach. In 100% (six of six) of the limbs, the head, neck, or dome of the talus was cut in a plane other than that of the articular surface of the talus. The distal articular surface of the talonavicular joint proved even more difficult to obliterate, with only 25% of the articular surface denuded. In one specimen, four puncture wounds were
e, Limb 1. Arrow shows intact cartilage of navicular.
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of the foot and ankle. Stability is restored after complete correction of the deformity and bony consolidation. A single lateral approach, as described by Ryerson,8 Hoke," and Campbell,2 is adequate to approach the subtalar and calcaneocuboid joints, but is inadequate to fully examine the talonavicular joint. With the exception of a severe varus deformity the talonavicular joint should be approached through an auxiliary medial incision in order to decrease the complication rate and increase the rate of fusion. In an age in which triple arthrodesis has become an increasingly uncommon operation for the general orthopaedist, we found that this technique is best rehearsed in the anatomy lab. Our data demonstrate why some results of the standard triple arthrodesis are poor and why certain complications are seen after this operation. This is not a "simple" operation!
ACKNOWLEDGMENTS The authors would like to thank Richard L. Uhl, M.D., and Marguerite M. Bohan, R.N.
REFERENCES
Fig. 6. A, B, Limb 3. Complete removal of cartilage of navicular and posterior facet of the calcaneus. Note remaining cartilage on talus over spring ligament (arrow).
discovered in the skin over the talonavicular joint. Injury to the neurovascular bundle on the medial aspect of the foot was not found in any of the specimens.
SUMMARY
A variety of diseases affecting the lower extremity have led to the development of stabilization procedures
1. Bono, J.V., and Jacobs, R.L.: Stabilizing procedures of the hindfoot. In Mastery of Orthopaedics, Ch. 107. Boston, Little Brown, 1992. 2. Campbell, W.C.: An operation for the correction of "drop-foot." J. Bone Joint Surg., 5:815, 1923. 3. Cracchiolo, A., III: Surgical arthrodesis techniques for foot and ankle pathology. In Instructional Course Lectures 49. Vol. 39, 1990. 4. Hallgrimsson, S.: Studies on reconstructive and stabilizing operations on the skeleton of the foot. With special reference to subastragalar arthrodesis in the treatment of foot deformities following infantile paralysis. Acta Orthop. Scand., 88(Suppl. 78):1, 1943. 5. Hoke, M.: An operation for stabilizing paralytic feet. J. Orthop. Surg., 3:494, 1921. 6. Jahss, M.H.: Disorders of the Foot. Philadelphia, W.B. Saunders, 1982, Ch. 1, p. 10. 7. Marcus, S.A., and Block, B.H.: Complications in Foot Surgery. Ann Arbor, MI, American College of Foot Surgeons, Books on Demand,1984. 8. Ryerson, E.W,: Arthrodesing operations of the feet. J. Bone Joint Surg., 5:453, 1923. 9. Tachdjian, M.D.: The Child's Foot. Philadelphia, W.B. Saunders, 1985.
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& ANKLE
Copyright © 1992 by the American Orthopaedic Foot and Ankle Society, Inc.
Triple Arthrodesis through a Single Lateral Approach: A Cadaveric Experiment* James V. Bono, M.D.,t and Richard L. Jacobs, M.D.:j: Albany, New York
ABSTRACT Using a single lateral approach, triple arthrodesis was performed on six cadaveric feet. An attempt was made to obliterate the talocalcaneal, talonavicular, and calcaneocuboid joints. The limbs were subsequently disarticulated to allow for an inspection of the talonavicular, talocalcaneal, and calcaneocuboid joints. An estimate of cartilage and subchondral bone removed from each articular surface was made by a single observer (J.V.B.) by direct visual inspection. Results were as follows: calcaneocuboid joint, 90% of cartilage removed; talocalcaneal joint, 80% of cartilage removed; talonavicular joint, 38% of cartilage removed. Failures at the talonavicular joint were attributed to a poor appreciation of the anatomy of the talar head and poor observation. Complications involved in obliteration of the talonavicular joint from a single lateral approach included: inadvertent division of the talar neck; inadvertent division of the talar head; removal of excessive bone stock; medial skin punctures; and creation of an iatrogenic cut through the talar dome. Therefore, a triple arthrodesis through a single lateral approach, as described by Ryerson,8 Hoke," and Campbell,2 cannot be recommended. The talonavicular joint should be approached through an auxiliary medial incision, as recommended by cracchlclc," This paper documents the experience of a beginner with this operation, and demonstrates the value of using the anatomy laboratory.
desis operation and reflects the learning curve associated with this procedure. By demonstrating the problems that an inexperienced surgeon can encounter, one may be able to identify the errors in procedure that contribute directly to a failed triple arthrodesis. We have attempted to study the effectiveness of this surgical procedure, performed by a resident in the anatomy laboratory, through a single lateral approach.
MATERIALS AND METHODS
Six cadaveric limbs were procured. A single straight incision, centered over the sinus tarsi, was carried down through skin, fascia, and subcutaneous tissues. The incision was extended from the peroneal tendons and directed anteriorly toward the head of the talus, and ended at the lateral border of the extensor tendons. The contents of the sinus tarsi were evacuated and the origin of the extensor digitorum brevis muscle was retracted distally. The capsules of the calcaneocuboid and talonavicular joint were incised, and the articular surfaces were obliterated with an osteotome. Similarly, the posterior facet of the talocalcaneal joint was identified just medial to the peroneal tendons and was obliterated. The procedure on all six limbs was carried out by one author (J.v.B.). At the completion of the experiment, the limbs were disarticulated to allow for inspection of the talonavicular, talocalcaneal, and calcaneocuboid joints.
INTRODUCTION
Triple arthrodesis through a single lateral approach is a technique that requires experience to do properly. This study represents a resident's (J.V.B.) experience in the anatomy laboratory rehearsing the triple arthro-
RESULTS
* This paper was presented at the American Academy of Orthopaedic Surgeons Meeting, Washington, DC, February, 1992 (poster exhibit). t Senior Resident, Division of Orthopaedic Surgery, Albany Medical College, Albany, New York :j: Professor and Chief, Division of Orthopaedic Surgery, Albany Medical College. To whom requests for reprints should be addressed at Division of Orthopaedic Surgery, Albany Medical College, Albany, New York 12208.
Ninety percent of articular cartilage was denuded from the calcaneocuboid joint space (Table 1). However, in 66% of these limbs, there was excessive removal of bone stock, which left a large dead space (Fig. 1). (This complication appeared in the first four cadaveric limbs dissected and was not present in the final 408
Downloaded from fai.sagepub.com at University of Otago Library on June 5, 2016
TRIPLE ARTHRODESIS
Foot & Ankle/Vol. 13, No. 7/September 1992
409
TABLE 1
Estimated Results of Foot
Joint surface
18
L
Proximal
2
R
Distal Proximal Distal . Proximal
4
R
Distal Proximal
5
L
Distal Proximal
6
R
Distal Proximal Distal
Removed at Each Joint
Talonavicular
Talocalcaneal
Calcaneocuboid
Neck of talus transected inadvertently 0 0 Head of talus transected 50 40 Inferior Dome of talus cut with osteotome with injury to tibial piafond 100 b 100 Good contour Head of talus cut 100 15 Head of talus cut 50 0 Head of talus cut 0 Missed 0
100
100 b
100 40 c
75 with fragmentation b 100 b
60 c 100 b
100 with fragmentation b 100 b
90 b 100 b
100 b .• 100 b
100 b 20'
100
100 50'
100 75
100
75 b
50
Extension of incision proximally. allowing translocation of peroneal tendons to reach posterior facet. This was found to be unnecessary. Excessive bone loss. c Posterior facet saddle shaped-inclines. then declines. Failure to appreciate contour of joint. (Inclined segment denuded and declining segment untouched.) d Medial skin over talonavicular joint punctured four times . • Disruption of peroneus longus tendon. , Not denuded down to subchondral bone. a
b
Fig. 1. Limb 6. Top arrow shows intact talonavicular joint. Osteotomy occurred across talar head proximal to talonavicular joint. Bottom arrow shows remaining cartilage of calcaneocuboid joint. Excessive removal of bone can create dead space.
two specimens, reflecting the learning curve involved with this operation). In one limb, excessive debridement of the calcaneocuboid joint was found to have disrupted the peroneus longus tendon where it courses under the cuboid (Figs. 1 and 2). The talocalcaneal joint proved to be slightly more difficult to obliterate than the calcaneocuboid joint, with 80% of the total joint surfaces denuded (Fig. 3). When the posterior facet of the calcaneus was examined, 90% of this articular surface was denuded, as compared with 70% of the articular surface of the posterior facet of the talus. In two limbs, the articular surface of the posterior facet of the talus had been debrided superficial to subchondral bone and was inadequate for the purposes of fusion. In limb 2, the posterior facet was saddle shaped, with an inclining anterior slope and a declining posterior slope; the convex nature of the posterior articular facet, as described by Jahss" and others,1,4,7,9 was especially pronounced. In this limb, only the inclining anterior portion of the posterior facet was obliterated (Fig. 3, A and B). In one third of the
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Foot & Ankle/Vol. 13, No. 7/September 1992
Fig. 2. A, a, Limb 5. Talonavicular joint. Osteotomy occurred across talar head, proximal to joint (top arrow). Note course of peroneal tendons across calcaneocuboid joint (bottom arrow).
limbs, there was excessive removal of bone stock of the talocalcaneal joint, which created a large dead space. The talonavicular joint showed the poorest results, with only about 40% of the articular cartilage denuded from the joint (Figs. 1-6). In limbs 5 and 6, the entire talonavicular joint was intact, despite what was thought to be a complete obliteration. An average of 50% of the articular surface of the head of the talus was denuded. However, in all six instances, the neck or head of the talus had been cut in a plane not parallel to the joint surface. In four out of six limbs, the head of the talus was partially transected. In limb 1, the neck of the talus had been transected. In limb 3, the osteotome had passed through the dome of the talus with
Fig. 3. A, B, Limb 2. Intact cartilage of navicular (top arrow) and posterior facet of the calcaneus (bottom arrow).
injury to the tibial plafond; this arose due to excessive bone stock removal of the posterior facet of the talus. The osteotome used to obliterate the joint space along the posterior facet had been sloped too severely, thereby cutting through the superior dome of the talus. In limb 3, there were also four discrete stab wounds over the medial skin about the talonavicular joint. The osteotomes introduced from the lateral approach violated the medial skin envelope.
DISCUSSION
Through a single lateral approach, the contents of the sinus tarsi were identified and evacuated easily. Extending the incision beyond the extensor tendons
Downloaded from fai.sagepub.com at University of Otago Library on June 5, 2016
Foot & Ankle/Vol. 13, No. 7/September 1992
TRIPLE ARTHRODESIS
411
Fig. 4. A, e, Limb 4. Cartilage remaining in midtarsal joint and spring ligament. Arrow shows intact cartilage of navicular.
Fig. 5. A,
medially or over the peroneal tendons laterally offered no advantage. Inspection of the floor of the sinus tarsi was the key to the entire operation. The subtalar joint was readily identified, just medial to the peroneal tendons, by its sharp anterior slope. It was not necessary to incise the peroneal sheath or translocate the peroneal tendons in order to access this joint. When denuding the subtalar joint, one should be careful not to incline the osteotome too sharply, for fear of cutting superiorly through the dome of the talus. In two specimens, insufficient bone stock was removed (superficial to subchondral bone), whereas in four specimens, excessive bone stock had been removed, which resulted in a large dead space. An appreciation of the slope of the posterior facet is essential to achieve a successful fusion.
The calcaneocuboid joint is the simplest of all three joints to obliterate in every way. However, excessive debridement of the joint in one situation led to disruption of the peroneus longus tendon, and in three limbs, it led to removal of excessive bone stock. The results at the calcaneocuboid joint were the best, with 90% of the articular surface removed. The majority of complications occurred at the talonavicular joint. This is a direct result of the poor accessibility of this joint from a single lateral approach. In 100% (six of six) of the limbs, the head, neck, or dome of the talus was cut in a plane other than that of the articular surface of the talus. The distal articular surface of the talonavicular joint proved even more difficult to obliterate, with only 25% of the articular surface denuded. In one specimen, four puncture wounds were
e, Limb 1. Arrow shows intact cartilage of navicular.
Downloaded from fai.sagepub.com at University of Otago Library on June 5, 2016
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BONO AND JACOBS
of the foot and ankle. Stability is restored after complete correction of the deformity and bony consolidation. A single lateral approach, as described by Ryerson,8 Hoke," and Campbell,2 is adequate to approach the subtalar and calcaneocuboid joints, but is inadequate to fully examine the talonavicular joint. With the exception of a severe varus deformity the talonavicular joint should be approached through an auxiliary medial incision in order to decrease the complication rate and increase the rate of fusion. In an age in which triple arthrodesis has become an increasingly uncommon operation for the general orthopaedist, we found that this technique is best rehearsed in the anatomy lab. Our data demonstrate why some results of the standard triple arthrodesis are poor and why certain complications are seen after this operation. This is not a "simple" operation!
ACKNOWLEDGMENTS The authors would like to thank Richard L. Uhl, M.D., and Marguerite M. Bohan, R.N.
REFERENCES
Fig. 6. A, B, Limb 3. Complete removal of cartilage of navicular and posterior facet of the calcaneus. Note remaining cartilage on talus over spring ligament (arrow).
discovered in the skin over the talonavicular joint. Injury to the neurovascular bundle on the medial aspect of the foot was not found in any of the specimens.
SUMMARY
A variety of diseases affecting the lower extremity have led to the development of stabilization procedures
1. Bono, J.V., and Jacobs, R.L.: Stabilizing procedures of the hindfoot. In Mastery of Orthopaedics, Ch. 107. Boston, Little Brown, 1992. 2. Campbell, W.C.: An operation for the correction of "drop-foot." J. Bone Joint Surg., 5:815, 1923. 3. Cracchiolo, A., III: Surgical arthrodesis techniques for foot and ankle pathology. In Instructional Course Lectures 49. Vol. 39, 1990. 4. Hallgrimsson, S.: Studies on reconstructive and stabilizing operations on the skeleton of the foot. With special reference to subastragalar arthrodesis in the treatment of foot deformities following infantile paralysis. Acta Orthop. Scand., 88(Suppl. 78):1, 1943. 5. Hoke, M.: An operation for stabilizing paralytic feet. J. Orthop. Surg., 3:494, 1921. 6. Jahss, M.H.: Disorders of the Foot. Philadelphia, W.B. Saunders, 1982, Ch. 1, p. 10. 7. Marcus, S.A., and Block, B.H.: Complications in Foot Surgery. Ann Arbor, MI, American College of Foot Surgeons, Books on Demand,1984. 8. Ryerson, E.W,: Arthrodesing operations of the feet. J. Bone Joint Surg., 5:453, 1923. 9. Tachdjian, M.D.: The Child's Foot. Philadelphia, W.B. Saunders, 1985.
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