Triple arthrodesis is a surgical procedure aimed at correcting severe foot deformities, specifically those affecting the hindfoot, where multiple joints are fused together. Originally designed to treat deformities due to neuromuscular diseases, this procedure has evolved into a powerful tool to address various forms of foot deformities, such as flatfoot, arthritis, and other structural issues. It is particularly effective in patients with severe, rigid deformities that do not respond to conservative treatments.
How Common It Is and Who Gets It? (Epidemiology)
Triple arthrodesis is most commonly performed in adults with severe foot deformities like adult-acquired flatfoot or arthritis. It is typically used when other treatments, such as bracing or physical therapy, have failed. Although the procedure is most commonly seen in middle-aged or older adults, it can also be used in younger individuals with neuromuscular disorders or traumatic injuries.
Why It Happens – Causes (Etiology and Pathophysiology)
The most common conditions that lead to triple arthrodesis include:
- Adult-Acquired Flatfoot: A condition where the arch of the foot collapses, leading to pain and instability.
- Arthritis: Both degenerative arthritis (such as osteoarthritis) and inflammatory arthritis (such as rheumatoid arthritis) can lead to the breakdown of joint cartilage and loss of function.
- Tendon Dysfunction: Conditions like posterior tibial tendon dysfunction, where the tendon that helps maintain the arch weakens, can result in foot deformities.
- Neurological Disorders: Conditions such as polio or Charcot-Marie-Tooth disease can lead to muscle weakness and abnormal foot positioning.
How the Body Part Normally Works? (Relevant Anatomy)
The foot consists of multiple joints, including the subtalar joint (between the talus and calcaneus), talonavicular joint (between the talus and navicular), and calcaneocuboid joint (between the calcaneus and cuboid). These joints allow for a range of movements that help with walking and maintaining balance. In triple arthrodesis, these three joints are fused to provide stability and pain relief, particularly in cases of deformities that disrupt normal joint function.
What You Might Feel – Symptoms (Clinical Presentation)
The most common symptoms that indicate the need for triple arthrodesis include:
- Pain: Persistent pain in the hindfoot or arch, often worsened by walking or standing.
- Deformity: A collapsed or misaligned arch that causes the foot to turn outward.
- Stiffness: Reduced range of motion in the affected joints.
- Instability: Difficulty maintaining balance or walking normally due to weakened joints.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is made through a combination of:
- Medical History: Understanding the patient’s symptoms and the extent of the deformity.
- Physical Examination: Assessment of foot alignment, joint stiffness, and walking patterns.
- Imaging: X-rays are used to evaluate joint degeneration, alignment, and the degree of deformity. A Saltzman hindfoot view, which shows the alignment of the hindfoot, is especially important in evaluating the need for surgery.
Classification
Triple arthrodesis is typically performed for severe, rigid foot deformities that are not amenable to other treatments. The condition is usually classified based on the underlying cause, such as:
- Adult-Acquired Flatfoot: Characterized by the collapse of the foot’s medial arch and outward tilting of the heel.
- Arthritis: Degenerative joint diseases that result in joint stiffness and pain.
- Tendon Dysfunction: Involving conditions like posterior tibial tendon dysfunction.
- Neurological Disorders: Conditions like polio or Charcot-Marie-Tooth disease that cause abnormal foot positioning.
Other Problems That Can Feel Similar (Differential Diagnosis)
Other conditions that can present with similar symptoms include:
- Ankle Fractures: Pain and deformity following trauma.
- Tendonitis: Inflammation of the tendons in the foot and ankle.
- Rheumatoid Arthritis: An autoimmune condition that affects joint function.
- Plantar Fasciitis: Inflammation of the foot’s connective tissue, leading to heel pain.
Treatment Options
Non-Surgical Care:
-
- Physical therapy to improve joint strength and flexibility.
- Orthotics or braces to provide support and realign the foot.
- Pain management through NSAIDs or corticosteroid injections.
Surgical Care:
-
- Triple Arthrodesis: Fusion of the subtalar, talonavicular, and calcaneocuboid joints to provide stability and relieve pain in cases of severe deformities.
Recovery and What to Expect After Treatment
After surgery, the foot is typically immobilized in a cast or boot to allow the joints to heal. Weight-bearing is usually restricted for 6 to 12 weeks. Once the bones have fused, physical therapy is initiated to restore strength and mobility. Full recovery can take up to 6 months, depending on the individual’s healing process.
Possible Risks or Side Effects (Complications)
- General Risks: Infection, scarring, and blood clots are common surgical risks.
- Specific Risks: Nonunion (failure of the bones to fuse), malunion (incorrect alignment), adjacent joint degeneration, and nerve damage.
- Postoperative Rehabilitation: Proper rehabilitation is crucial to ensure that the foot heals in the correct position and to restore function.
Long-Term Outlook (Prognosis)
Triple arthrodesis is highly effective at providing pain relief and restoring stability in the foot. Most patients experience significant improvements in gait and mobility. However, the procedure involves a loss of joint flexibility, which may affect some activities. Long-term success depends on proper rehabilitation and avoiding excessive stress on the foot.
Out-of-Pocket Cost
Medicare
CPT Code 28715 – Triple Arthrodesis (Fusion of the Subtalar, Talonavicular, and Calcaneocuboid Joints): $221.63
Medicare Part B typically covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining 20%, significantly reducing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans coordinate with Medicare to fill the coverage gap and lower your overall financial responsibility.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans typically cover any remaining balance, including coinsurance or small deductibles, which typically range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your triple arthrodesis is required due to a work-related injury or condition, Workers’ Compensation will cover all related medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly covers all approved treatments.
No-Fault Insurance
If your triple arthrodesis is needed because of an automobile accident, No-Fault Insurance will typically cover the total cost of your treatment, including surgery and recovery. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your policy.
Example
James Harrison needed a triple arthrodesis (CPT 28715) to correct severe arthritis in his foot. His estimated Medicare out-of-pocket cost was $221.63. Since James had supplemental coverage through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the surgery.
Frequently Asked Questions (FAQ)
Q. What is Triple Arthrodesis?
A. Triple Arthrodesis is a surgical procedure that fuses three joints in the hindfoot (the subtalar, talonavicular, and calcaneocuboid joints) to treat severe foot deformities like flatfoot, arthritis, or tendon dysfunction.
Q. What conditions are treated with Triple Arthrodesis?
A. It is commonly used to treat conditions such as adult-acquired flatfoot, arthritis, tendon dysfunction (e.g., posterior tibial tendon dysfunction), and foot deformities due to neurological disorders.
Q. How is Triple Arthrodesis performed?
A. The surgeon makes incisions to access the three joints in the hindfoot, removes damaged cartilage, aligns the joints, and fuses them using screws or other hardware to ensure proper healing in the correct position.
Q. What are the benefits of Triple Arthrodesis?
A. The procedure provides pain relief, restores foot stability, and improves mobility by correcting deformities, particularly in patients with severe foot deformities that don’t respond to conservative treatments.
Q. What are the risks of Triple Arthrodesis?
A. Risks include nonunion (failure of the bones to fuse), malunion (incorrect alignment of the fused joints), infection, adjacent joint degeneration, and nerve damage, although these complications are relatively rare.
Q. What is the recovery time after Triple Arthrodesis?
A. Recovery typically involves 6 to 12 weeks of non-weight bearing with a boot or cast, followed by gradual weight-bearing and physical therapy. Full recovery can take up to 6 months.
Q. Can Triple Arthrodesis be performed on both feet at the same time?
A. While it is technically possible to perform the procedure on both feet, it is typically done one foot at a time to allow for proper healing and reduce the risk of complications.
Q. Is physical therapy required after Triple Arthrodesis surgery?
A. Yes, physical therapy is crucial after Triple Arthrodesis to help restore strength, flexibility, and range of motion in the foot, as well as to improve walking and prevent stiffness.
Q. Will I experience any loss of motion after Triple Arthrodesis?
A. Yes, the procedure involves fusing three joints, which will result in a loss of some foot motion. However, the trade-off is increased foot stability and pain relief, which improves overall function.
Q. How long does the Triple Arthrodesis procedure take?
A. The surgery usually takes about 2 to 3 hours, depending on the complexity of the deformity and whether additional procedures are needed.
Q. Will I be able to walk immediately after Triple Arthrodesis?
A. No, you will need to avoid putting weight on the foot for several weeks to allow the joints to heal. Crutches or a walking boot will be used to protect the foot during recovery.
Q. Can Triple Arthrodesis be done on children?
A. Triple Arthrodesis is generally not recommended for children, as their bones are still developing. The procedure is more commonly performed in adults with severe foot deformities or arthritis.
Q. How effective is Triple Arthrodesis for correcting foot deformities?
A. Triple Arthrodesis is highly effective for correcting severe foot deformities, especially those caused by arthritis or tendon dysfunction. Most patients experience significant pain relief and improved foot stability.
Q. Are there any long-term complications of Triple Arthrodesis?
A. Potential long-term complications include arthritis in adjacent joints due to altered foot mechanics, as well as a risk of further deformities or instability in the ankle or midfoot.
Q. Can Triple Arthrodesis be combined with other foot surgeries?
A. Yes, in some cases, Triple Arthrodesis can be combined with other procedures, such as tendon transfers or soft tissue releases, depending on the patient’s needs and the severity of the deformity.
Summary and Takeaway
Triple arthrodesis is a highly effective procedure for treating severe foot deformities by fusing three joints in the hindfoot to restore stability and reduce pain. While it does result in a loss of joint flexibility, the trade-off is improved foot function and pain relief, which is especially beneficial for those suffering from conditions like flatfoot, arthritis, or tendon dysfunction. With proper preoperative planning, skilled execution, and diligent postoperative care, triple arthrodesis can significantly improve quality of life for patients with severe foot deformities.
Clinical Insight & Recent Findings
A recent study described a unique case of ankle-preserving surgery to correct instability that developed years after a triple arthrodesis. The patient, who had undergone the original procedure for a clubfoot deformity, later experienced worsening ankle instability due to residual varus malalignment.
Instead of performing an ankle fusion, surgeons used a combination of distal tibial oblique osteotomy and lateral displacement calcaneal osteotomy to restore alignment and maintain motion at the ankle.
The approach successfully corrected the deformity, improved stability, and preserved ankle function for more than four years, demonstrating that joint-preserving revision can be a viable alternative to ankle fusion in select cases after triple arthrodesis. (“Study on joint-preserving correction after triple arthrodesis – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Orthopedic surgeons specializing in foot and ankle surgery typically perform triple arthrodesis. In some cases, a multidisciplinary team, including physical therapists and rehabilitation specialists, may be involved in the postoperative care.
When to See a Specialist?
If you are experiencing persistent foot pain, deformity, or difficulty walking due to conditions like flatfoot or arthritis, it’s important to consult a specialist to determine if triple arthrodesis or another surgical procedure is necessary.
When to Go to the Emergency Room?
Seek emergency care if you experience severe pain, sudden loss of function, or a traumatic injury to the foot that may require immediate attention.
What Recovery Really Looks Like?
Recovery from triple arthrodesis involves several months of rehabilitation. Initial non-weight-bearing is followed by gradual reintroduction to normal activities. Full recovery may take up to 6 months, with rehabilitation helping to restore mobility and strength.
What Happens If You Ignore It?
Ignoring severe foot deformities can lead to worsening pain, further deformity, and loss of mobility. Early intervention with procedures like triple arthrodesis can prevent further damage and improve long-term outcomes.
How to Prevent It?
Preventing foot deformities involves maintaining proper foot health, wearing supportive footwear, and avoiding excessive stress or trauma to the feet. Regular foot check-ups can help identify early signs of deformities.
Nutrition and Bone or Joint Health
A balanced diet rich in calcium and vitamin D supports bone health, which is essential for managing foot deformities and aiding recovery after surgery.
Activity and Lifestyle Modifications
After surgery, low-impact exercises such as swimming or cycling are ideal for maintaining fitness without stressing the foot. High-impact activities should be avoided until full recovery is achieved.
Dr. Mo Athar
