Triple Arthrodesis: Purpose, Procedure, Benefits and Side Effects

Triple Arthrodesis is a surgical procedure which combines three adjacent joints together in the foot or ankle. Commonly performed to correct problems with gait or alignment of the foot, it is also a treatment option for severe arthritic conditions in one or more of these joints.

There are three types of this procedure which surgeons may choose from depending on the severity of the patient's condition:-

• Chaly-Touil Arthrodesis: It is an open procedure that involves fusion of the three major bones of the foot, namely talus, calcaneus and navicular bones. This technique also allows for some correction in alignment of the joint surfaces as well as correction for any malalignment of tendons or ligaments around them. It is generally used for patients with severe cases due to arthritis or trauma.
• Scarff-Larson-Banks (SLB) Triple Arthrodesis: This technique has been recently developed and involves arthroscopic fusion of the tarsal bones using screws and plates without requiring any tissue disruption. This technique is used for mild to moderate cases due to its minimal invasiveness and rapid recovery time for patients compared with open surgery techniques such as Chaly-Touil arthrodesis.
• Bose Triple Arthrodesis: This technique includes an open surgery but uses multiple smaller incisions instead of one larger one, making it less invasive than Chaly-Touil arthrodesis. It was initially developed mainly for children where careful preservation of joint motion was essential but can be used in any case where motion preservation and minimal trauma are important considerations such as athletes playing sports that require running and jumping movements that would otherwise require more extensive surgeries with more associated risks than Bose triple arthrodesis offers

• The main benefit of Triple Arthrodesis is that it can provide long-term stability.
• In some cases, this surgery can even permanently stop mobility between the fused joints.
• Additionally, it has a great rate of success in providing relief from heel and arch pain caused by iatrogenic (medical treatment) conditions such as severe arthritis or flatfoot deformity.
• In addition to long-term stability and pain relief, Triple Arthrodesiology also aids in improved joint mobility by reducing degenerative changes on the other joints' surfaces as they compensate for movements once served by the totally fused joints.
• For athletes who are looking to return to their sport after Triple Arthrodesis, good outcomes may depend on proper pre-operative rehabilitation in order to reduce postoperative swelling and pain which could affect healing time.

• Triple Arthrodesis is a surgical procedure used to treat conditions such as Charcot-Marie-Tooth Disease, recurrent joint dislocation and severe arthritis that cause pain in the foot and ankle.
• It is done by surgically fusing together the three long bones that make up the ankle: the tibia, fibula, and talus.
• The primary goal of this surgery is to reduce pain and improve function by providing a stable environment for these three bones to heal while limiting motion in the area.

• Infection: Triple arthrodesis involves cutting through soft tissue and bone, which increases the risk of infection.
• Complications from anaesthesia: Anesthesia can cause potential side effects, such as nausea, dizziness, and confusion.
• Nerve damage: The surgery can potentially cause nerve damage, leading to pain, numbness or tingling in the affected area.
• Blood clots: A blood clot can form after surgery, resulting in a potentially life-threatening condition called deep vein thrombosis (DVT).
• Joint stiffness: After the surgery, the joint may become stiff due to scar tissue formation or lack of movement.
• Arthritis: Arthritis is a possible complication of triple arthrodesis due to increased stress on the remaining joints in the foot.

To make sure you're prepared for this procedure, your doctor may recommend that you:-

• Have a physical exam prior to surgery. Your doctor will evaluate your overall health and discuss any potential risks or complications associated with a triple arthrodesis.
• Have any necessary diagnostic tests done before the day of surgery such as an X-ray or CT scan of your feet.. These tests help the surgeon plan for the correct positioning of your feet during surgery.
• Have laboratory tests done which may include blood work and urinalysis for infection screening and possible anaemia evaluation before undergoing this type of procedure.
• Avoid taking certain medications before surgery such as aspirin or ibuprofen because these can increase bleeding risk during and after the procedure is performed.
• Discuss any allergies that you have so that appropriate anaesthesia can be used during the procedure if needed . Make sure to list all past medications that have caused allergic reactions in addition to foods and environmental allergens too.. Lastly, make sure all questions are answered so there are no surprises once you arrive in the operating room on the day of surgery..
• Stop Smoking if applicable since smoking can impede wound healing time following any type of foot procedure like a triple arthrodesis

• The surgeon begins the procedure by preparing the foot and ankle for surgery.
• Next, the surgeon cuts and removes damaged bones in the foot and ankle, including the talus, calcaneus, and navicular bones.
• The surgeon then places metal screws in the remaining bones to hold them together while they heal.
• The surgeon may also use a bone graft to fill any gaps between the bones and help them fuse together more quickly.
• Finally, the surgeon applies a cast or brace to keep the foot in place while it heals.

• Complete physical examination including X-rays of the foot
• Evaluation of pre-operative radiographs to assess the extent of the deformity
• Evaluate the patient’s activity level and plan for postoperative rehabilitation
• Explain the procedure and its risks to the patient and family
• Obtain informed consent from the patient or guardian
• Administer preoperative antibiotics
• Administer preoperative pain medications and sedation as needed

• Make an incision over the foot.
• Isolate and expose the articulations between talus, calcaneus and navicular bones by performing a subperiosteal dissection of the joint capsule, ligaments and soft tissues.
• Resect bone from the talar dome, navicular or calcaneal surfaces as needed to ensure a proper joint gap for arthrodesis.
• Place a suitable arthrodesis plate to span across the three joints and secure it to each articular surface with screws; ensure that all screws are inserted into a solid bony portion of each joint to maximise stability.
• Check for misalignment with fluoroscopy; if malrotation is detected then recut the distal surface of either navicular or calcaneus with an osteotome until satisfactory alignment is achieved while preserving rigid congruence between talar dome and distal surface elements involved in fusion process again ensuring suitable joint gap width for arthrodesis constructs placement
• Close incisions in layers with absorbable sutures, sterile dressings and protective bandages
• Cast or splint application which immobilises deformity can later be done if necessary

• Obtain vital signs and assess:
  • Check temperature
  • Monitor heart rate and blood pressure
  • Check for pulse oximetry
  • Assess neurovascular status:
  • Palpate all three sites (ankle,subtalar,transverse tarsal) for pulses to check viability of neurovascular structures.
  • Elevate the foot 6-8 inches above the level of the heart and maintain this position while in bed with pillows-to limit swelling, edema, and possible hematoma formation around the arthrodesis site.
  • Apply ice to arthrodesis site-to reduce swelling, pain, muscle spasms
  • Administer analgesics as ordered to reduce pain
  • Instruct patient about postoperative care guidelines:
  • Avoid excessive weight bearing for best results
  • Wear a non weight bearing cast or a splint for several weeks after surgery depending on intraoperative findings
  • Educate patient about preventing contractures by performing regular range of motion activities on other joints of lower extremities such as knee and hip flexors/extensors as directed by healthcare providers to promote healing through improved circulation as well as strengthening of soft tissues muscles around a new joint

The exact cost of a Triple Arthrodesis procedure in India will depend on several factors such as the type of hospital, the doctor's experience, and the complexity of the case.

Generally speaking, it can cost anywhere from 25,000-1.2 lakhs INR. It is important to do research and compare prices from different hospitals to ensure that you get the best deal possible.

• It is important to eat a healthy and nutritious diet after having a triple arthrodesis or any kind of surgical procedure.
• Eating nutrient-rich foods can help speed up the healing process and prevent further complications.
• Consume foods that are rich in protein, complex carbohydrates, and healthy fats such as lean meats, fish, nuts, beans and whole grains.
• Eating fruits and vegetables will provide you with much needed dietary fibre and essential vitamins and minerals that can aid in recovery.
• Drink lots of water to stay hydrated.

Triple arthrodesis is generally considered a safe procedure, although it does involve some risks associated with any surgical procedure, such as infection and nerve damage.

Yes, triple arthrodesis is a major surgical procedure and is typically associated with significant amounts of pain.

• Generally, patients can expect to take several weeks to recover from this surgery.
• The first 6-8 weeks after the procedure are typically spent in a splint or cast, allowing the feet to heal correctly.
• After this period of immobilisation, weight bearing will slowly be reintroduced and physical therapy started.
• During physical therapy exercises will be completed to slowly restore mobility and flexibility in the affected area.
• Recovery may take anywhere from 10-12 weeks with some cases taking up to 6 months depending on how quickly your feet heels and responds to treatment.

• The most common side effects of a triple arthrodesis procedure are:-
• Swelling and stiffness in the affected joint
• Pain and discomfort at the site of surgery
• Numbness or muscle weakness due to displacement of the nerve or tendon in the operated joint
• Limited range of motion and difficulty walking
• Infection at the surgical site
• Anxiety, depression, or sleep disturbances following surgery.

• Rest your feet for 3-6 weeks.
• Wear a hospital provided post-operative shoe for 8-12 weeks and follow your doctor's instructions for “non-weight bearing”. Non-weight bearing means that you shouldn't be standing, walking, or bearing weight on your affected foot while the arthrodesis is healing.
• You may perform some gentle stretching of the ankle and toes with your toes pointed upward with no resistance or pain to encourage healing and motion of the foot joint. The muscles may begin to atrophy if you don't move them regularly, leading to further decreases in flexibility and strength over time.
• Follow up with your doctor approximately 6 months after surgery in order to determine how much weight can be supported on the joint as it heals, as well as allowing any necessary changes in immobilisation methods if needed such as splints or post operative braces to assist with additional care required if needed throughout recovery period post surgery.
• Make sure you take anti-inflammatory medications during this time period if necessary but always consult doctors prior to taking any medications on regular basis in order not to interact with other drugs that might interfere with the effects of the medication being taken already by the patient pre or post operation
• Monitor your incisions for signs of infection such as increased pain, redness, swelling or drainage from the site; ensure keep all incision sites clean and free from damage until fully healed; contact physician immediately should any signs/symptoms of infection arise during recuperation period following surgery completion

The triple arthrodesis procedure is a complex and technically demanding surgery that can be utilised to treat several conditions, including Charcot arthropathy, tarsal coalition, midfoot and hindfoot arthritis, as well as traumatic or degenerative diseases of the ankle. The procedure also has a high success rate with satisfactory long-term outcomes that improve patient quality of life.